9.2 How To Develop Effective Intersectoral Partnerships

9.2.1 Articulate a common values base and language

An important first step in developing effective partnerships was, in several cases, a systematic effort dedicated to clarifying the language used. Harder than it sounds, this process required first of all a mutual recognition that fundamental differences in perspective could be clouded by imprecise language, or by terms that were commonly used without being clarified. This seemed to be especially critical where partners worked in domains that bounded each other: close enough that they used the same terms, but with a very different underlying approach. Examples would be in the case of health promotion versus social services, or public health and community development. Working toward the articulation of a common language inevitably meant making values explicit, and sometimes entailed negotiating common ground on value positions. This process was invaluable among those who had worked through it, in terms of deepening their mutual understanding and clarifying their values base.

9.2.2 Foster trust

Trust among the partners is a key feature in effective intersectoral partnerships, and a critical factor in sustaining and growing the initiatives. How this trust develops is a bit magical to all concerned: the secret formula seems to be a combination of having the right people, combining maturity and experience with effective interpersonal skills and compassionate, inclusive values, who work in an environment that allows them to take risks and to use their personal judgement while keeping their eyes on the main goal of population health and well-being. Trusting relationships are not instantaneous: they are built over time, as people gain experience with each other in a variety of situations and over a variety of issues. The development of trust results in a shared working space for population health that participants experience as safe, supportive, and sometimes, healing. They know and understand each other and each other's perspectives, and have the commitment and capacity to work through problems together. Moreover, these bonds are sometimes strong enough to keep people involved even though it was no longer their official business to do so. Rachlis observed that "the failure to maintain teams of people decreases the trust necessary for collaboration"¹⁰: these case studies suggest that trust can actually maintain teams of people.

An important lesson comes from the observation that when partners understand each other's perspectives, they are able to analyze emerging situations as a function of the other's positions. This facilitates the sharing of information - partners know what will be of interest or value for their colleagues to know - but also allows the partners to act quickly on opportunities that will benefit the entire group, in the name of the group, or to be secure in the knowledge that their partners would have done the same. This greatly increases the agility of the population health dossier, ensuring that it can be maximally responsive to changing situations and emerging issues.

9.2.3 Demonstrate flexibility and tolerance for instability

Inevitably, in the tumultuous organizational lives of the partners involved in these initiatives, changes, constraints and difficulties have come to stand in the path of their full contribution for a time, to hobble their role, or to dry up their resource contributions. Effective intersectoral collaborations have seemed able to take these in stride, almost without comment, and to find ways to adjust and reroute so that the partnerships could continue. This degree of flexibility has ensured that in some cases, partnerships that might have been jeopardized were simply left on simmer for a time. It also has contributed to the sense of security that partners have felt in the collaboration, as they have understood that should they ever face a similar situation, it would be accepted and dealt with positively in the partnership.

9.2.4 Start collaboration vertically, then move horizontally, but watch for opportunities

As a result of the choices and opportunities they have faced, the various intersectoral networks of the initiatives have varied in their horizontality (across all the sectors touched upon by a particular problem), as well as in their verticality (through all levels of government with interest or mandate related to the problem).

Each type of collaboration has presented specific challenges and advantages, but overall, it seems that the initiatives have found it more effective to start from a vertical perspective for a number of reasons connected to the considerations described above. Individuals working within the same sector in different levels of government already tended to know each other or of each other from previous collaborations or previous career stops; they thus already had a good sense of who was and was not an ally in the population health approach. Second, the steps of articulating a common language and values base tended to be shorter (although frequently still necessary) when working vertically. Finally, forming a common vertical front of the health sectors from all levels of government has also seemed to provide a strong starting position from which to advance into other sectors.

On the other hand, pursuing horizontal collaboration in some cases has opened opportunities to profit from the momentum of service integration efforts within provinces, or from the reach of special inter-departmental task forces or units that provinces were using to examine related issues. Still, for several of the initiatives, developing effective partnerships outside the health sector has been a challenge, in terms of deciding how to go about it, and then identifying and gaining collaborators who were able to buy in with the same level of commitment to working on the determinants as those in the health sector.

9.2.5 Collaboration with provincial, municipal or other governments

Many of these initiatives have involved collaboration with provincial governments, often through health or other human service departments, and some have worked with other levels of government including municipal or First Nations' governments. A lesson that emerges from these collaborations is that effective joint work is clearly possible; it can also go a very long way to furthering population health aims by promoting a coherent message, pooling resources to work more efficiently, and providing added momentum and value from the collaborative process itself. Another lesson is that such collaborative work must proceed with all due respect for mandates and jurisdictions. When that respect is present, the resulting levels of trust enable inter-governmental partners to find creative solutions to barriers imposed by federal/provincial and other inter-governmental relations and mechanisms, and to ride out together any white caps of political weather.

Working with multiple provincial governments, as was the situation in one of the cases (but which could eventually apply to at least one other region), provided an additional layer of challenges. These governments need to be careful with each other, in all of their bi-, tri- and multi-lateral arrangements. In our one particular case, intersectoral collaboration was aided by locating the leadership for the initiative in a neutral, non-governmental organization with a regional mandate.

9.2.6 Collaboration with regional health authorities

In most parts of the country, regional health authorities are where the rubber meets the road in terms of enacting the population health approach in health and social services resource allocation, organization and delivery. In those cases where collaboration with health authorities was part of the collaborative scenario, the initiatives learned to work from a capacity-building perspective, recognizing that these organizations have borne the brunt of health care reform in recent years, and have seen great human resource and organizational upheaval, with their attentions focussed primarily on the curative side.

9.2.7 Collaboration with other federal departments

For many - but certainly not all - of these initiatives, the development of intersectoral partnerships with other federal departments and agencies has been disappointingly limited, even though some key departments were already embracing similar perspectives. As Rachlis has noted with understatement, "the organization of government into separate departments compromises intersectoral action for health."¹¹ That silos exist between departments is not a surprise to anyone; that they should be harder to break down between federal departments than with provincial governments might be. Interestingly, in three situations touched on by the case studies, collaboration among provincial departments was enhanced by the work of overarching inter-ministerial bodies: this may be an instructive model for future thinking about population health mobilization among federal departments.

9.2.8 Collaboration with community-based groups

Community-based groups have been key partners in four of the six initiatives, and some interesting lessons have emerged from these collaborations. First, as many of the community-based respondents in the case studies have noted, although partnerships and coalitions with other community groups were basic modes of operation, collaboration with governments was sometimes quite new, and tended to shift the dynamics around. Several community-based interviewees commented that they had learned a great deal about the workings of government with respect to policy development through their participation in the intersectoral collaboration, and had developed a greater appreciation for the challenges on the other side of the fence as a result. This suggests that population health mobilization can contribute to the development of more productive and constructive relationships among community-based organizations concerned with advocacy in social and health issues than have existed in the past.

9.2.9 Collaboration with university researchers

In the three cases where the university sector was involved, it played very different roles: as project coordinator and facilitator, as key partner, and as adjunct knowledge developer. In all of these cases, the contribution has been significant and useful but arose from the same considerations as for the other players: like-mindedness, willingness and skills to work collaboratively, and trust.

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10. M. Rachlis, op. cit., p. 22.

11. M. Rachlis, op. cit., p. 22.

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