COALITIONS, CONSORTIA, AND PARTNERSHIPS

"Rich together, poor if separated" (Laos); "One finger cannot lift a pebble" (Iran); "United we stand, divided we fall" (United States). These aphorisms and hundreds others like them suggest that the idea of people and groups forming alliances and coalitions, and the inherent value of such actions, is universal.

The concept of "community" has long been a fundamental component in the design and implementation of health and social programs. Funding agencies and researchers have learned that ignoring or downplaying community members' perspectives can jeopardize an otherwise well-designed intervention. Similarly, ambitious strategies that have incorporated community strengths and engaged community members constitute some of public health's most significant success stories.

The terms "community" and "community based" have particular appeal in public health, where they are virtual shorthand for a number of basic tenets. First, they highlight public health's emphasis on populations, as opposed to the medical system's focus on individual health. Second, a community focus acknowledges that individual health behaviors are strongly influenced by the infrastructure and social norms that make healthful choices easier or harder to adopt. Finally, close examination of health-status indicators (e.g., infant mortality rates, the prevalence of HIV [human immunodeficiency virus] infection) quickly reveals the connections between health problems and their social determinants, such as poverty, housing, and education. These determinants tend to cluster geographically—in communities or neighborhoods within communities.

THE TERMS—DIFFERENCES AND SIMILARITIES

The terms "consortia" and "coalition" are frequently used interchangeably in the context of public health, but there are subtle distinctions worth noting. A consortium is typically an alliance of organizations, usually with a common mission and purpose, that seeks to gain a benefit that could not be achieved independently. For example, several health clinics might form a consortium in order to jointly purchase equipment that would have been prohibitively expensive for any one clinic. Or, to enhance their ability to provide a seamless system of care, that same collection of clinics might develop a common case-management system to coordinate the children's health services they provide.

In contrast, a coalition is usually an alliance of organizations with potentially diverse purposes and missions. Given a broad goal of mutual benefit, the central challenge faced by coalitions is to coordinate the diverse strengths of multiple partners. For example, given a broad goal of tobacco control, an effective coalition might try to influence policymakers on several fronts, including seeking to develop or enforce local ordinances banning smoking in public places, conducting campaigns to raise cigarette taxes, and enforcing laws making tobacco less accessible to children. Each individual member of the coalition might not pursue these initiatives (or might not pursue them effectively), but the coalition's united front is its strength.

Perhaps more significant than the subtle differences between consortia and coalitions are the similarities they share. These similarities are captures in the more colloquial term—partnership. In the context of community health, partnership refers to the relationships among two or more organizations in which each has equal status and a certain independence, while maintaining a formal obligation toward a mutual goal they agree could not be achieved alone.

No matter how different their primary goals may be, consortia and coalitions often have common secondary goals. These include generating additional resources, raising community awareness, and the formation of alliances to support other community organizations or groups. Finally, most public health consortia and collaborations described in the literature are, at least in part, supported by funding from outside the coalition. (In many cases, outside funding was the catalyst for their formation in the first place.) Consequently, both consortia and coalitions share the challenges of working with one or more funding organizations and of matching collaborative activities to the funders' expectations.

COMMUNITY PARTICIPATION

Inherent in the spirit of a coalition is another assumption: that community participation mutually benefits both the community and the program. For example, there is evidence that community participation can lead to individual and community empowerment, as coalition members gain skills in assessing needs, setting priorities, and obtaining funding. At the same time, active community representation and participation reflects a sentiment that the coalition is being responsive and "true" to community needs that, in turn, can translate into increased credibility for the coalition's message or programs and, potentially, lead to more resources.

CHALLENGES

Not all coalition efforts are successful. Researchers have identified several factors that may help explain why some coalition efforts struggle to attain the outcomes they desire. A major source of difficulty seems to be that coalitions are too often held to unrealistic expectations. Collaboration among multiple organizations and the people who represent them is difficult, time-consuming, and often tedious work. Furthermore, because coalitions often rely on volunteer labor from their members, it is difficult to assign and complete basic planning and implementation tasks that many observers consider essential to the success of collaborative efforts.

Bringing together groups with diverse missions and interests is a task that requires a clear vision, diplomacy, and considerably more time than is usually estimated. Failure to take these realities into account can lead to unrealistic time, resource, and outcome expectations, and, as a result, perceived failure. Accordingly, public health professionals would be well advised to think carefully about what is and is not feasible for collaborative mechanisms to accomplish, and if necessary, to scale back expectations.

Finally, some researchers have suggested that the efforts of coalitions have gone undetected because of inappropriate or weak evaluation plans. This is most likely to occur when: (1) the evaluation timeline is too short; (2) the evaluation strategy focuses on unrealistic, distant health outcomes instead of intermediate indicators influenced by coalition activity; (3) evaluation measures are incapable of detecting valid indicators of change; or (4) when alternative explanations for effects are not taken into account. For many coalition or partnership endeavors, a realistic scaling back of expectations will offer more opportunities for accountability and for holding collaborative efforts to mutually agreed upon standards of performance. For example, several investigators have demonstrated that it is quite feasible to establish a system to document changes in community systems and policies that are related to coalition activities. When these changes are documented cumulatively over time, they reflect a reasonable and appropriate reflection of a coalition's immediate impact and, although not necessarily directly, lead to changes in more distal outcomes.

SUCCESSES

These challenges notwithstanding, the public health and social sciences literature is replete with well-documented reports showing that collaborative approaches are strongly associated with the achievement of targeted objectives and outcomes. Practitioners and researchers who have extensive experience with public health coalitions appear to be in general agreement on the question of what factors are repeatedly associated with coalitions that are deemed successful.

Clear Vision and Mission. The goal and intent of the coalition needs to be well understood and endorsed by coalition members. Coalitions that frame their intended objectives with specificity (e.g., increasing childhood immunization or improving employment outcomes) appear to be more successful than those where the mission and objectives are vague.

A Plan of Action. Coalition members should agree on a plan or logic model that links the activities of the coalition to intermediate, measurable objectives that are, in turn, linked to the coalition's ultimate goals and mission. The plan also takes into account anticipated timelines, personnel (coalition members and staff) required to fulfill specific roles, and overall economic resource needs.

Leadership. It is important to have a respected individual or group of individuals who champion the cause of the coalition and ensure that the actions of the participants focus on the coalition's ultimate mission.

Documentation. A system is necessary to facilitate the routine and periodic recording of coalition activities and intermediate outcomes.

Communications. A systematic commitment should be made to keep coalition members and all stakeholders aware of the coalition's aims, activities, and progress. Systematic results from a documentation system are essential to a meaningful and effective communication plan.

Resources. Adequate personnel, staff and technical assistance, and economic resources are necessary to carry out and sustain coalition functions.

The notion of democratic participation can be powerfully compelling and even seductive. While unifying people to achieve a goal of shared communal interest is a powerful and often effective process, the difficulty and investment required to implement and sustain such collaborations should not be obscured. Successful collaborative efforts absorb time, resources, and goodwill. Often, these investments are worthwhile, either because coalitions achieve some of their outcomes or because their intermediate by-products (such as trust, participation, and goodwill) enhance the social norms for community wide health improvement. Everyone involved in collaborative work—coalition or consortium members, their funders, and the members of the communities they serve—should be fully aware of the costs and benefits of the task they are undertaking and set fair expectations for this participatory, inclusive way of organizing the ambitious and endless work of improving the health of communities.

Marshall Kreuter

Nicole Lezin

(see also: Citizens Advisory Boards; Community Health; Community Organization; Enabling Factors; Health Goals; Health Promotion and Education; Leadership; Participation in Community Health Planning; Social Networks and Social Support )

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