7: No. 6, November 2010
Julie Woulfe; Thomas R. Oliver, PhD, MHA; Susan J. Zahner, DrPH, RN; Kirstin
Q. Siemering, DrPH
Suggested citation for this article: Woulfe J,
Oliver TR, Zahner SJ, Siemering KQ. Multisector partnerships in population
health improvement. Prev Chronic Dis 2010;7(6):A119.
Many new initiatives for population health improvement feature partnerships
of leaders and organizations across multiple sectors of society. The purpose of
this article is to review 1) the rationale for such partnerships as an
important, if not essential, tool for population health improvement; 2) key
organizational and contextual factors that appear to be associated with
effective multisector partnerships; and 3) the limited evidence regarding the
effect of such partnerships on population health outcomes. We conclude that
systems thinking — accounting for the collective effect of many actors and
actions — is essential to organizing and sustaining efforts to improve
population health, and to evaluating them. More research is needed to
understand how and why multisector partnerships are formed and sustained and
the conditions under which multisector partnerships are necessary or more effective
than other strategies for population health improvement. Research on and evaluation
of multisector partnerships also need to incorporate more standard measures of
partnership contexts, characteristics, and strategies and adopt longitudinal and
prospective designs to accelerate social learning in this area. Finally, studies
of multisector partnerships must be alert to the value of such initiatives to
individuals and communities apart from any direct and measurable impact on
Back to top
In response to the call of the Institute of Medicine for multisector
partnerships (1), many new
initiatives for population health improvement feature partnerships of leaders
and organizations across multiple sectors of society. These partnerships
typically include representatives and resources from various substantive issue
areas — for example, education, economic development, transportation,
agriculture, and health — and span the business, nonprofit, and governmental
sectors. The purpose of this article is to review 1) the rationale for such
partnerships as a tool for population health improvement, 2) key organizational
and contextual factors that appear to be associated with effective multisector
partnerships, and 3) the limited evidence regarding the effect of such
partnerships on population health outcomes.
Back to top
The Case for
During the past 3 decades, efforts to improve population-wide health outcomes
have moved toward community organizing and collaboration. Community organizing
refers to the unit of analysis and action, shifting the focus from individuals
to systems, rules, social norms, or laws to affect health behaviors and outcomes
(2). This ecologic approach recognizes the connection between health and social
institutions, surroundings, and social relationships (3).
Collaboration refers to the process of system change, shifting the focus from
the responsibilities and effectiveness of individual institutions to their
relationships and collective effect on population health. In particular, efforts
have increased to involve many sectors of a community in pursuit of better
health outcomes and the economic and social benefits thought to be associated
with such outcomes. The rationale behind multisector partnerships is that,
because no single organization or sector has full control over
the determinants of population health, effective solutions require
interorganizational coordination and collaboration (4). By pooling resources,
talents, and strategies from a broad range of actors, each of these sectors can
more effectively carry out its responsibilities as they affect population health
(2). Researchers have advanced similar theories of collaboration to improve the
effectiveness of initiatives on related issues such as poverty and community
Researchers have conceptualized partnerships for health improvement
differently. Three dominant models of partnerships for health improvement have
been described (4). In the first, public health agencies are primarily
responsible for promoting activities and services that affect the health of the
community. Their partnerships with other organizations exist primarily to extend
the reach and capacity of governmental public health. In the second, many
organizations play some role in promoting public health and so must be involved
in health improvement. However, the focus remains primarily on the delivery of
public health services. The third model focuses on the system of actors and
actions that promote or threaten population health and includes
activities in all sectors of community life (eg, education, business) (4). This
last model, the most ecologic of the 3, has received increasing attention.
However, the evidence to date suggests that these large-scale community
health promotion projects have changed population health behaviors and outcomes
only moderately (5).
In response to the mixed results of approaches based on the third model, some
argue it is necessary to reconceptualize partnerships for health improvement
(6). According to this argument, even the broadest partnerships have not shifted
from an individual intervention paradigm to a true systems paradigm. Systems
thinking focuses on the collective influence of a broad range of actors. It
recognizes communities as networks of dynamic, nested relationships among
individuals and organizations. These constantly evolving complex adaptive
systems comprise diverse agents operating in various subsystems and
suprasystems without centralized control (7). Although most partnerships adopt
interventions targeting multiple levels within a system, they may fail to
recognize the full scope and complexity of the system and miss opportunities to improve population health. Hawe and colleagues (6)
argue that unique problems are associated with scaling up partnerships from the
organizational level to the community level. They suggest that these
partnerships learn from ecologic-systems perspectives that examine linkages,
relationships, feedback loops, and interactions among systems. From this
approach, multisector partnerships can be conceptualized as events within
systems that either leave a lasting footprint or wash out, depending on how well
the dynamic properties of the system are harnessed. The success of a partnership
depends on activity settings, the social networks that connect people and
settings, and time (6).
Recent work on social networking approaches to collaboration examines the
importance of looking at the effect of a particular intervention rather than
measuring the changes in a system over time. In network approaches, leaders
focus not only on management challenges and opportunities at an organizational
level but also on how to mobilize resources more broadly for the greatest social
Drawing from these approaches, a fourth conceptualization of multisector
partnership seems to emerge. This model focuses not only on the relationships
among organizations in the partnership but also on the partnership’s
relationship to the context of the place it is trying to change.
In some ways, this model is a continuation of the focus on neighborhood-based
and community initiatives. However, it adds a new emphasis on considering the
characteristics of context, including the timing of the intervention and past
events, particularly earlier interventions that may have created networks. From
this perspective, partnerships work to build capacity over time and consider the
impact on the context itself as the primary outcome.
Back to top
Key Factors in the
Effectiveness of Multisector Partnerships
Extensive research has identified the qualities perceived as contributing to
strong multisector partnerships in health and other issue areas. This section
summarizes some of the lessons learned about the most important dimensions of
Partnership resources include the money, skills and expertise, information,
and connections that a partnership has to draw on (9). Although resources
alone do not ensure the success of partnerships, how partnerships are funded and
supported does influence their functioning (10). Some common themes are the
necessity of sufficient resources, the sustainability of resources, and whether
funding supports the partnership’s original mission and vision (8,9,11). In
addition to sustainable funding, the flexibility of funding is
important to long-term success (12). Coalitions may need access to information
and support in the form of ongoing technical assistance (10), which enables the partnership
to evaluate and change its
Common vision for partnership
Multisector partnerships bring together groups with disparate interests and
roles. One of the most universally recognized needs is a common vision for the
partnership’s projects, goals,
and outcomes (13).
Partnerships without clear goals that rely on broad agendas may become
distracted by emerging crises and side issues. Another risk is to become so
narrowly focused that the partnership ignores important community and contextual
issues. A related concern is ownership of the vision for the project.
Researchers emphasize that communities that are being served by the partnership
must contribute to the vision for the project, creating a sense of ownership
and empowerment (10,14).
Effective leadership is one of the most studied characteristics of effective
partnerships (10,15-17). Leadership style can vary from collaborative leadership
to a more hierarchical model. Whatever the style, however, effective leadership
inspires commitment and action, helps the partnership to work toward
inclusion, and works to sustain the vision and participation of the
partnership’s members (10,15).
Research demonstrates the importance of building leadership at many levels. Along with leaders who possess expertise and experience in the issue
area, collaborations need sponsors who can provide resources to the enterprise
and champions who possess the necessary process-oriented skills to keep the
collaboration going. Champions are particularly important because
a diverse organizational partnership may lack a clear-cut strategy that
can be centrally developed and easily enforced (18).
The effectiveness of partnerships depends on their organizational structure
and capacity. As with leadership, no one form can serve all partnerships equally
well. Effective partnerships appear to share several features, however,
including clear structure, adequate staffing, sufficient core resources, and
transparent decision-making processes (10,13,16).
A core test of organizational structure and process is the ability of a
partnership to deal with conflict. In multisector collaborations, conflict is
common and emerges from the marriage of different organizational cultures with
varied views about planning, strategies, and tactics. Collaborations that have
continual trust-building activities are more likely to manage potential
conflict. Conflicts exist not only at an individual level but also at the
systemic level. Consequently, collaborations are more likely to succeed when they
build in resources and tactics for dealing with power imbalances (18). To
achieve a broad consensus of how to proceed, the partnership should develop
norms, rules, and processes based on the input of all members of the
partnership. The planning must also involve the broader network of affected
parties and attend to the stakeholders (18).
Selection of the right partners is necessary for success.
Partnerships aimed at community health improvement should include a broad array
of partner organization types (11). Membership diversity refers to members’
social identity (ie, racial, ethnic, or cultural identity) and how well they
represent the community the partnership serves (16).
Building a culturally diverse membership increases the likelihood
that the interventions will be culturally appropriate and strengthens the
community’s investment in the partnership. Attracting broad membership and
community investment requires partnerships to demonstrate how their issues
relate to the broader concerns of the partners and the community as a whole (13).
There are potential risks, however, in forming new collaborations.
Recruitment of members presents a tradeoff between representativeness and
effectiveness. Up to a point, expanding representation can increase legitimacy
and attract more resources for an initiative. But coalition size and
diversity may make it harder to reach decisions and develop and implement new
programs (T. R. Oliver and J. Gerson, unpublished report to The California Endowment, October 2006).
Although newly constituted partnerships may have the advantage of not being
obligated to any particular community group, they may lack credibility and
power. Partnerships must therefore strategically align themselves with
established groups (12). Bryson et al (18) found that cross-sector
collaborations were more likely to succeed when 1 or more linking mechanisms
(ie, existing networks, powerful sponsors) were already in place. Thus, building
from existing relationships may be more effective than forging completely new
ones (18). Research on which members are most valued by partnerships indicates
that the most valuable member has a well-connected presence in the
community, can devote resources to the collaboration, and actively participates
Forty coalition leaders named commitment to the cause as the main element of
coalition success. Additional factors named were commitment to coalition unity,
breadth of representation, continuing contribution of resources, and previous
history of working relationships (17).
Quality of relationship
In addition to the desired structural characteristics of partnerships, the quality of
the relationship distinguishes effective partnerships from ineffective
ones. This sense of collaboration or group cohesion is complex and difficult to operationalize. Nonetheless, strong collaborative working relationships are
often credited with allowing multisector partnerships to provide integrated
service delivery (15,16). Good communication among partners, transparency in
decision making, and accessible, jargon-free language better enable partners to
participate effectively. Communication and ongoing feedback enable the
partnership to grow and evolve. Effective partnerships have been successful in
establishing a sense of mutual trust, respect, and commitment (13). Overall,
effective coalitions and partnerships bond individuals in addressing a concern
together, creating a sense of community and connection (10).
External and contextual factors
The influence of community characteristics on the success of collaborations
is a subject of growing interest. Some communities may have more readiness or be
more conducive to the work of the partnership (9,10). Feinberg and colleagues
(20) examined the relationship between 3 dimensions of community coalition
readiness and the perceived effectiveness of the coalition. In a study that
evaluated leadership readiness, community readiness, and strength of community
ties, they found that community readiness is positively related to the perceived
efficacy of coalitions (20). A community’s readiness may be affected by capacity
built through prior partnerships, the presence of competition between and within
sectors, and the degree to which a community is already saturated with similar
Communities each come with their own public and organizational policy
barriers to partnerships. Financial barriers may include short-term or limited
external funding, lack of funding for administration and management, and
categorical program requirements. Other barriers may include performance
standards or current benefit requirements that discourage key leaders or
organizations from participating (9).
Although external factors affect the success of collaborations, the research
on community coalitions suggests that the collaboration’s response to those
factors is more important to the development of the collaboration. Members of
community coalitions routinely name political, economic, and community
conditions as important in coalition development. However, they identify additional factors as more
important, such as choosing a relevant issue,
having the right timing, and choosing an appropriate social target (17).
Back to top
Evidence of the Effectiveness of Partnerships
Despite a common belief that multisector collaboration can improve population
health, researchers seldom study the effect of such collaboration on population
health outcomes. Evaluating the effect of multisector partnerships
on population health outcomes is difficult. Some of the most-cited challenges
are the short study period of evaluations, limited use of evidence-based logic
models and theories of action to guide interventions, the difficulty of
measuring the degree of individual exposure to interventions, and multiple or
broad population indicators (21).
Researchers fail to agree on what factors are most closely linked to improved
population health outcomes. Often these factors have been drawn from a broad
review of literature from multiple disciplines, each defining efficacy
differently (14). Even researchers who agree that a particular quality of a
coalition is important may disagree about how to measure that quality (16).
In a review of hundreds of collaborations, Roussos and Fawcett (21) could
identify only 34 evaluations of partnerships working locally to address
community health that had a study design or logic model to guide their work. Of
the 34 partnerships, 10 presented improved population-level outcomes that might
be attributed to collaboration activities. The review found stronger support for
the ability of collaborations to change behavior and systems. Of the 34
studies of partnerships, 15 included measures of behavior change, 14 of which indicated some shift in behavior. All 34 studies reported
some sort of systems change in the form of new programs developed, funds
generated, or other measures (21).
Another literature review (16) yielded similar results. The authors searched
major databases for studies on partnerships that targeted local geographic areas
to improve population-level health outcomes, and defined and measured both
coalition effectiveness and coalition-building factors. The review noted that
across studies, researchers have defined and operationalized coalition-building
factors and effectiveness differently. Studies had different definitions of
coalition functioning, often failed to connect coalition-building factors to
coalition effectiveness, and yielded mixed results (16). One study concluded
that multisector partnerships and interventions continue to be driven primarily
by ideology and action rather than sound scientific design and evaluation (22).
Back to top
Kreuter and Lezin (23) observe that justifications for collaborating to change health status and health systems fall into 2
major categories, conventional wisdom and evidence. Of the 2 justifications,
conventional wisdom is vastly more common in the literature. The need for
continued research and evaluation of broad-based initiatives to improve
population health is clear, given the challenges of studying the influence of multisector partnerships in complex systems. Further research is needed to
understand the circumstances in which formal multisector partnerships are likely
to be formed, the extrinsic and intrinsic motivations of leaders and members,
and how to increase the commitment of members through incentives and other
means. In addition, further research is needed to identify whether and how
multisector partnerships affect both the levels of population health and
disparities within a population and to clarify what characteristics of
partnerships and what contextual conditions are necessary for improved health
outcomes. Finally, more research is needed to examine the comparative
effectiveness of multisector partnerships and other strategies for improving
population health, in particular, when the leadership and resources required to
organize and maintain formal partnerships are not necessary to improve
health outcomes or reduce health disparities.
General lessons are available: first, systems thinking is essential to
organizing and sustaining efforts to improve population health, and to assessing
their impact. The outcomes of partnership approaches depend on the social,
economic, and political context of the community in which partnerships are
formed and operate. Only by studying the varying contexts can researchers
discern whether any form of partnership is sufficient for population health
Second, characteristics of partnerships — goals, sponsorship, membership,
resources, leadership — do appear to matter, but this has been established
primarily through studies based on perceptions of participants rather than
objective measures of outcomes. Therefore, more research is needed on
multisector partnership outcomes using longitudinal and prospective designs that
include measurement of activities, social network development, and types of
organizations involved and resources engaged. To aid this area of inquiry,
better and more widely adopted measures of structure, process, and outcomes are
needed to link partnership formation to community-wide impact. One step toward
building a stronger evidence base of what works would be the adoption of common
models or frameworks for defining different forms of public health partnerships
— for example, the typology offered by Mays (4). Standard models, as well as
more standard measures of partnership contexts, characteristics, and strategies,
would improve the generalizability and replicability of research and accelerate
Third, multisector partnerships almost certainly offer some value to
individuals and communities apart from any direct and measurable effect on
population health. The shared effort and communication that result from a health
initiative may highlight problems, shift resources, or raise expectations for
participation and performance in other areas of community life. Studies of
multisector health partnerships should be alert to such catalytic changes and
spillover effects as researchers pursue a clearer view of the connections
between partnerships and population health improvement.
Back to top
This work was funded by the Robert Wood Johnson Foundation as part of the
Mobilizing Action Toward Community Health project at the University of Wisconsin
Population Health Institute.
Back to top
Corresponding Author: Thomas R. Oliver, PhD, MHA, Department of Population Health
Sciences, University of Wisconsin School of Medicine and Public Health, 610
Walnut St, 760 WARF, Madison, WI 53726-2336. Telephone: 608-262-6731. E-mail:
Author Affiliations: Julie Woulfe, Kirstin Q.
Siemering, University of Wisconsin Population Health Institute, Madison,
Wisconsin; Susan J. Zahner, University of Wisconsin-Madison, School of Nursing,
University of Wisconsin Population Health Institute, Madison, Wisconsin.
Back to top
- Institute of Medicine, National Academy of Sciences. The future of public
health in the 21st century. Washington (DC): National Academies Press; 2003.
- Butterfoss FD. Coalitions and partnerships in community health. San
Francisco (CA): John Wiley and Sons, Inc; 2007.
- Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE; Task Force on
Community Preventive Services.
model for linking the social environment to health. Am J Prev Med 2003;24(3 Suppl):12-20.
- Mays GP. Improving public health system performance through
multiorganizational partnerships. Prev Chronic Dis 2010;7(6). http://www.cdc.gov/pcd/issues/2010/nov/10_0088.htm.
- Merzel C, D’Afflitti J.
Reconsidering community-based health promotion:
promise, performance, and potential. Am J Public Health 2003;93(4):557-74.
- Hawe P, Shiell A, Riley T.
Theorising interventions as events in systems. Am
J Community Psychol 2009;43(3-4):267-76.
- Keshavarz N, Nutbeam D, Rowling L, Khavarpour F.
Schools as social complex
adaptive systems: a new way to understand the challenges to introducing the
health promoting schools concept. Soc Sci Med 2010;70(10):1467-74.
- Wei-Skillern J. Networks as a type of social entrepreneurship to advance
population health. Prev Chronic Dis 2010;7(6).
- Lasker RD, Weiss ES, Miller R.
Partnership synergy: a practical framework
for studying and strengthening the collaborative advantage. Milbank Q
- Wolff T.
A practitioner’s guide to successful coalitions. Am J Community Psychol 2001;29(2):173-91;discussion
- Zahner SJ.
Local public health system partnerships. Public Health Rep
- Stagner MW, Duran MA.
Comprehensive community initiatives: principles,
practice, and lessons learned. Future Child 1997;7(2):132-40.
- Green L, Daniel M, Novick L.
Partnerships and coalitions for community-based
research. Public Health Rep 2001;116(Suppl 1):20-31.
- Mayer JP, Sweid R, Dabney S, Brownson C, Goodman RM, Brownson RC. Practices
of successful community coalitions: a multiple case study. Am J Health Behav
- Hayes CE, Hayes SP, DeVille JO, Mulhall PF. Capacity for
effectiveness: the relationship between coalition structure and community
impact. Eval Program Plann 2000;23(3):373-9.
- Zakocs RC, Edwards EM.
explains community coalition effectiveness? A review of the literature. Am J Prev Med 2006;30(4):351-61.
- Mizrahi T, Rosenthal BB.
Complexities of coalition building: leaders’
successes, strategies, struggles, and solutions. Soc Work 2001;46(1):63-78.
- Bryson JM, Crosby BC, Stone MM. The design and implementation of
cross-sector collaborations: propositions from the literature. Public Adm Rev
- Varda DM, Chandra A, Stern SA, Lurie N.
Core dimensions of connectivity in
public health collaboratives. J Public Health Manag Pract 2008;14(5):E1-7.
- Feinberg ME, Greenberg MT, Osgood DW. Readiness, functioning, and perceived
effectiveness in community prevention coalitions: a study of communities that
care. Am J Community Psychol 2004;33(3-4):163-76.
- Roussos ST, Fawcett SB.
A review of collaborative partnerships as a strategy
for improving community health. Annu Rev Public Health 2000;21:369-402.
- O’Neill M, Lemieus V, Groleau G, Frotin J, Lamarche P. Coalition theory as a
framework for understanding and implementing intersectoral health-related
interventions. Health Promot Int 1997;12(1):79-87.
- Kreuter MW, Lezin NL. Are consortia/collaboratives effective in changing
health status and health systems? A critical review of the literature. Atlanta
(GA): Health 2000; 1998.
Back to top
Comment on this
article at PCD Dialogue
Learn more about PCD's