Exploring the unanticipated effects of multi-sectoral partnerships in chronic disease prevention
Introduction
Collaborative approaches, such as partnerships, alliances, coalitions, and networks, have a long history in public health, including for preventing chronic disease [1], [2], [3]. These approaches are thought to help distribute the risks and responsibilities of health more broadly, exchange knowledge and experience among partners, and improve the planning, implementation and impact of public health programs [4], [5], [6], [7]. With this potential value, much attention has been given to the processes of building and maintaining collaborative approaches, that include developing a shared vision among partners, ensuring sufficient financial resources, building useful monitoring, accountability and improvement strategies, and fostering trust among partnership members [1], [7], [8], [9], [10], [11]. Yet the complexity of public health challenges is demanding new approaches to building, sustaining, evaluating and improving partnership-based initiatives [1].
Many public health problems are now recognized as complex, considered as those with a large number of diverse elements, whose interactions produce emergent and unpredictable effects [12], [13], [14], [15]. Complex problems, including those related to behavior change at a population level and altering environments, rarely respond to single, simple or one-off solutions [13], [16], [17]. In contrast, complex problems require complex interventions, involving multiple components, that target multiple levels in a socio-ecological system, and that adapt and change in response to different contexts [18], [19], [20], [21], [22]. In public health, complex interventions have been designed to address many health issues, including tobacco control, unhealthy diets, and childhood obesity [15], [23], [24], [25], [26], [27]. Partnerships are critical vehicles for implementing and improving these interventions, and are responding to the complexity imperative in multiple ways, including how they are structured and who they engage.
Increasingly, partnerships in public health are seeking to leverage new resources through engaging private and not-for-profit sector organizations, which is consistent with concepts related to collaborative value, social innovation, and collective impact [29], [30], [31]. Much has been written about public–private partnerships, their risks and benefits, critical success factors, and conditions under which they may be most appropriate [2], [4], [7], [32], [33], [34], [35], [36]. In public health, public–private partnerships may involve a range of organizational members, including those from government agencies and departments; non-government organizations and charities; academic, university and school-based settings; as well as those from for-profit industries. Despite their potential in leveraging complementary resources, uncertainty exists regarding their ability to equitably, efficiently and effectively address population health needs [10], [36], [37], [38].
Chronic disease prevention provides a useful setting for examining contemporary approaches to public–private collaboration in public health. Chronic diseases such as cancer, cardiovascular disease and diabetes are the primary causes of death and disability in most developed economies [39], [40], [41], [42]. Chronic diseases are also widely regarded as complex problems, influenced by individual physiological and psychological factors through to broad environmental conditions [42], [43]. In seeking novel solutions to these complex problems, governments are turning to private sector partners with expertise in diverse fields, such as finance, retail, media, construction, urban design and food production and retail.
In Canada, the Federal Government has recently launched a partnership based initiative designed to engage diverse organizations in the fight against chronic disease. The Public Health Agency of Canada’s Multi-sectoral Partnerships to Promote Healthy Living and Prevent Chronic Disease (hereafter referred to as the MSP initiative) was designed to be more responsive to the conditions that support the development of complex health interventions and to improve the capacity of government and non-government partners in designing, delivering and measuring preventive health activities. Since its launch, the MSP initiative has evolved from a traditional funding mechanism through which Government funded not for profit organizations to undertake community based activities, to one of Canada’s first multi-sectoral, social finance approaches. In contrast to conventional Government funding programs that involve a bilateral relationship between the Government and a not-for-profit organization, the MSP initiative requires the investment of resources (both financial and skill-based) from a variety of sectoral partners including academic, not-for-profit and the private and foundational sectors, both within and outside health.
To enable this shift, the MSP Initiative has moved from a fixed proposal solicitation approach to an on-going Letter of Intent solicitation process that engages Government, potential applicants and partners from the early stages of idea development. The MSP initiative also requires 1:1 matched funding (as well as other non-financial contributions) from non-taxpayer funded sources or private sector partners, allowing diverse sectors to contribute to chronic disease prevention, and to share mutual risk, recognition and reward.
Practically, program staff at the Agency now play an essential role in brokering new relationships with and between potential partners to meet project requirements for funding, and to seek important contributions such as evaluation capacity, access to program delivery settings and expertise in program design and implementation. The initiative has also introduced a pay for performance system, where payments are tied to jointly negotiated and measurable outputs/outcomes. Now in its fourth year, the MSP initiative continues to evolve as it considers integration of other social finance concepts, including the development of Canada’s first Social Impact Bond in health [44].
Since its launch in 2013, the MSP initiative has provided financial support for 30 projects involving public–private partnerships with durations of 2–5 years that have focused on interventions targeting unhealthy eating, physical inactivity, tobacco use and injuries [44] (although at the time of conducting this study, there were 23 funded projects). These projects have goals for achieving changes at individual and/or environmental levels, with a focus on improving access to resources, healthy environments and promoting healthy behavior change [45], [46]. Given the focus on partnerships, additional desired effects related to partnerships have also been articulated by the Agency, although not necessarily translated into or shared with other partners as explicit goals. These additional effects include addressing the determinants of health outside the health sector, expanding the government’s capacity to share skills, expertise and opportunities; increasing capacity for action at provincial, national and international levels; and securing long term and sustainable impact of interventions [45].
In addition to these intended effects, there is also a wide range of other effects that may occur as a result of the MSP initiative, particularly for those people and organizations investing in this way of working. These effects may occur in relation to a broad range of issues, such as partner knowledge, awareness, attitudes, perceptions, practices or beliefs. They may also relate to effects of multi-sectoral partnerships on individuals, organizations or communities, and may be intended outcomes by some players and unanticipated by others.
Given this range of potentially broad effects, their influence on those working in partnerships as well as the performance of the partnership itself, and that relatively little is known about their occurrence, this study aimed to identify and describe the unanticipated effects of multi-sectoral partnerships for chronic disease prevention from the perspectives of those working within such partnerships.
Section snippets
Methods
This study employed a qualitative multiple case-study design, involving participants from three purposefully selected partnership projects funded as part of the Agency’s MSP initiative (the ‘cases’). The perspectives identified in this study are therefore limited to those involved in a large partnership-based initiative from Canada. The study involved four phases: (1) case identification; (2) participant recruitment; (3) data collection and analysis; and (4) feedback to participants and Agency
Results
Seventeen individuals across the three cases were contacted and 13 (76%) completed an interview. All cases were represented, however, two of the five partners in one case were unreachable after three communication attempts and one interviewee was unable to complete the interview at the scheduled time. One interview involved two participants. One interview was conducted in French. The interviewees represented partners from academia (n = 1), government (n = 5), not-for-profit (n = 2) and private
Discussion
This study has identified a range of effects from MSPs in chronic disease prevention that were unanticipated for partnership members. While these effects were unanticipated for those participating in this study, they resonate with insights from the literature on MSPs, and also some of the desired outcomes of the Agency for the MSP initiative.
Conclusions
This study has identified a gap between what is known about multi-sectoral partnerships, and the experiences of those within them for chronic disease prevention. For those who participated in this study, surprises existed in the role and approach of government, in the resources made available to partners, in the capacities that may be built, and in the time required to work in successful multi-sectoral partnerships. The newness of these insights for those within these partnerships suggests
Conflict of interests
The authors declare that they have no conflicts of interests to declare.
Funding
Funding for this study was provided by the Public Health Agency of Canada (the Agency). Some members of the Agency were also participants in this study. The Agency assisted in formulating study aims and provided business contact details for members of funded partnership projects. The Agency did not participate in study design, data collection or data analysis. One member of the Agency participated as an author of the manuscript. Contributions from Propel were supported by the Canadian Cancer
Ethics approval and consent to participate
The study was approved by the University of Waterloo Research Ethics Committee (ORE#21129).
Authors’ contributions
CW designed the study, contributed to data collection procedures and tools, data analysis and drafting the manuscript. CC contributed to study design, developing data collection procedures and tools, collecting and analyzing data and drafting the manuscript. LS contributed to data collection procedures and tools, collecting and analyzing data and drafting the manuscript. JG contributed to forming research questions, facilitating data collection, and drafting the manuscript. BR contributed to
Acknowledgements
The authors wish to acknowledge the contributions made to this study by members of the Public Health Agency of Canada, as well as Drs. Robyn Plunkett and Jennifer Yessis from the Propel Centre for Population Health Impact for assistance in data collection and analysis.
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