Critical Public Health,Vol. 11, No. 3, 2001
Empowering healthcare workers in Africa: partnerships in health—beyond the rhetoric towards a model WALID EL ANSARI* & CERI J. PHILLIPS** *School of Health Care, Oxford Brookes University, UK; **School of Health Sciences, University of Wales Swansea, UK
A B S T R A C T In most African nations, the trumpet has sounded for joint-working, inter-agency working and multi-sectoral working. However, there are a number of lessons to be learned from collaborative schemes and initiatives that have been undertaken. In particular, attention needs to be drawn to the ‘black box’ where interactions between the diverse partners take place, irrespective of the ‘package’ the stakeholders hope to deliver to the targeted beneéciary population. The analysis of collaboration as a ‘process’ then becomes imperative. This paper describes collaboration and partnerships: their strategic levels, organization and structure, stage of development, membership capacities and effectiveness. Drawing on two examples of collaborative initiatives from South Africa, it identiées and analyses the challenges that face administrators and professionals involved in joint working efforts. Given the multiple facets that collectively contribute to a ‘successful’ collaboration, the paper suggests a framework for understanding partnership work. If health partnership schemes in Africa are to go beyond the rhetoric, many skills and diverse expertise need to be invested in multiple aspects of the efforts. The paper concludes that the presence, development and transfer of the necessary skills are needed for successful joint delivery of programmes.
Introduction Collaboration:To work jointly with others on a project.Those collaborating with others take on speciéed tasks within the project and share responsibility for its ultimate success. (Michigan State University, 1996) Collaboration is the development of a model of joint planning, joint implementation, and joint evaluation between individuals or organisations. (New England Program in Teacher Education, 1973)
Correspondence to: Dr. Walid El Ansari MBBCh, Dip(Ped), DTM&H, MSc(PHM), PGCert (HE), ELR (SA), PhD, Senior Lecturer in Public Health & Epidemiology, Public and Community Health Department, School of Health Care, Oxford Brookes University, Heritage Gate, Sandringham House, Sandy Lane, Oxford OX4 6LB, UK. Tel: +44 (0) 1865 488125; fax: +44 (0) 1865 488126; email:
[email protected] OR
[email protected] Critical Public Health ISSN 0958-1596 print/ISSN 1469-3682 online © 2001 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/09581590110066676
232 Walid El Ansari & Ceri J. Phillips Collaboration between health and social care is essential (Social Exclusion Unit, 1998) if targets are to be reached (Statham, 2000). Sectoral approaches to complex problems cannot mobilize the full range of resources required to effect sustainable change (Clark et al., 1993), and while strategic planning has given way to strategic partnering, the notion of competitive advantage has been transformed into the idea of collaborative advantage (Shannon, 1998). The shift is from separatism between services and patronage on the part of the professional to partnership, and the word ‘partnership’ is used to indicate a ‘shift’ to greater equality in relationships (Statham, 2000). Partnership was considered the watchword for the 1990s. Community partnerships bring local people together to identify and tackle needs through constructive two-way dialogue (Proctor & Campbell, 1999). Given that ‘community’ is regarded as a set of power relations within which people are grouped (Navarro, 1984), partnerships are a means of balancing power and acknowledging absolute interdependence (Block, 1993). Partnerships bring different configurations of professionals, practitioners, service representatives and the lay community together to develop joint contracts to reduce health inequities (Proctor & Campbell, 1999). In recent years social (also known as public–private) partnerships have emerged as a major ‘new’ mechanism for solving difécult problems (El Ansari 1998a;Waddock & Bannister, 1991). It is at this point that the primordial ancestor and common thread of partnership fostering the ‘art and science’ of joint working (Lindsay & Edwards, 1988) comes into action. The collaboration inherent in a partnership is more than a mere exchange—it is the creation of something new, of value, together (Kanter, 1994). Mounting such a ‘creation’ requires an enormous amount of work and effort that is frequently underestimated but essential to move a partnership to a different level of functioning (Shannon, 1998). As the obstacles to collective action are considerable (Herman et al., 1993; El Ansari & Phillips, 1998, in press), collaborative planning through successful alliances and coalitions that facilitate the development and operation of social capital are subject to a variety of challenges. Overcoming the challenges will require more managerial and énancial infrastructure for public involvement, additional attempts to engage communities (Fisher et al., 1999), a range of skills which few health professionals currently have (Neve, 1996; Carlson & El Ansari, 2000), the often-deficient element of appreciation of each other’s expertise (El Ansari, 1998b), and, more importantly, robust ‘models’ and conceptual frameworks that can guide practitioners and administrators. The aim of this paper is to describe the processes and development of partnerships as regards their strategic levels, organizational and structural characteristics, stages of development, membership and effectiveness.The multiple aspects of successful partnership fostering are then linked together in a framework that serves as a conceptual model to guide practitioners involved in joint working efforts.
Empowering healthcare workers in Africa 233 The development of partnerships Partnerships and collaboration have been viewed as two different points on the same joint-working continuum (Shannon, 1998). Coalitions are formal structures of relationships among individuals or groups, all of which are banded together for a common purpose (Kaplan, 1985). It is the commitment to a common cause— frequently purposive change (Roberts-DeGennaro, 1987)—that characterizes these coalitions, whether the partners are organizations and individuals (Staggenborg, 1986), voluntary confederations of independent agencies (Lindsay & Edwards, 1988) or community assemblies mounting on multipurpose and long-term alliances (Butterfoss et al., 1993). While unity and purpose are fundamental aspects of coalitions, other necessary factors include (1) the need to be issue-oriented, structured and focused to act on speciéc external goals and committed to recruitment of diverse and resourceful member organizations (Stevenson et al., 1985; Allensworth & Patton 1990); (2) the support of the member organizations, who also simultaneously advocate on behalf of the partnership itself (Hord, 1986; Feighery & Rogers, 1989); (3) elements of durability (Sink & Stowers, 1989; Wandersman & Goodman, 1991) and endurance (Thompson & Kinne, 1990), as a more enduring, coordinated and comprehensive local effort is more likely to have impact (Kumpfer et al., 1993; El Ansari, 2000a). At the policy level partnership is attractively simple and economically sound, where resources are pooled (Statham, 2000). At the local level different skill mixes are pulled together to promote health or safer communities, while at the individual level partnerships can deliver support to individuals (Statham, 2000), enhance self-esteem (Moskowitz, 1989) or change community norms (Hansen & Graham, 1991). In the health-promotion field, at the micro level are partnerships which do not seek to affect the underlying systems or architecture, while at the macro level alliances and partnerships seek to affect the structural determinants of health (Gillies, 1998). At the front line, however, partnerships are employed to deliver a complex range of services that change as community needs change (Statham, 2000), and successful partnerships need to make a difference to the lives of people (Butt & Mizra, 1996; Morris, 1996). Certain structural characteristics, such as the development of a mission, by-laws, and clearly deéned member roles and responsibilities, must be present for coalitions to function effectively (Rogers et al., 1993; El Ansari & Phillips, 1997).The organizational factors include member relationships, member–staff relationships, communication patterns and the quality of communication (Butterfoss et al., 1993). An organizational structure must be developed which promotes collaboration among actors from different sectors (Florin et al., 1992), as the structure provides context for planning, communicating, managing and evaluating (Gottlieb et al., 1993). A congruency between complexity of purpose, degree of formality of agreements and centralization of authority, and the nature of leadership and decision making is necessary for optimal functioning (Habana-Hafner et al., 1989).
234 Walid El Ansari & Ceri J. Phillips Different sets of factors are intricately linked to the stages of development of a partnership. The formation stage occurs at the initiation of funding and formation of committees, and soon gives way to the implementation stage, where committees conduct needs assessment to determine the constituents’ concerns and develop intervention plans.The maintenance stage consists of monitoring and continuance of the committees and activities, while the outcome stage comprises impacts (Butterfoss et al., 1993). Kreuter et al. (2000) described a pre-formation (pre-planning) stage, followed by formation, and then implementation and maintenance stages. However, little empirical work has been done to understand the coalition development processes (Francisco et al., 1993) or the complex developmental tasks (Bracht & Kingsbury 1990; Florin, Chavis et al., 1992). In order to study coalition maintenance, one needs to establish the point at which a coalition moves from formation to maintenance. Once the organizational actors coalesce around an issue(s), mobilize resources, and establish a purpose and a leader, for all practical purposes the coalition has been formed (Roberts-DeGennaro, 1987). The maintenance is the process of supporting the life of the coalition, in order to keep it from declining and to sustain it against opposing forces. It is also important that members have the skills or ‘capacity to participate’ in order to operate an effective partnership (Gray, 1985). In voluntary participation, the competence and the performance of members and organizations are positively related to successful collaboration. Useful skills are the expertise in multiple dimensional team building; the use of temporary systems; planning and meeting technology skills; and involvement competences (Balcazar et al., 1990; El Ansari, 2000b). Conèict utilization abilities and how to utilize resistance to change as a positive force; appreciation of differences while decreasing turfdom loyalties and defences; competence in recognition and ‘footnoting’ participants’ contributions; and, evaluation and feedback competences are also valued (Schindler-Rainman & Lippitt, 1977; Schindler-Rainman, 1981). In assessing the effectiveness of partnership working, Waddock and Bannister (1991) articulated two perspectives. First, the programmatic perspective, measured by assessing the inputs, processes and outputs, is the more traditional assessment of organizational effectiveness (Quin & Cameron, 1983; Quin & Rohrbaugh, 1983). The second perspective addresses the preconditions and processes essential to making interorganizational collaborations work and focuses on the interaction among partners, as determined by the processes that brought the partners together and that hold them jointly over time (Gray, 1981, 1985, 1989;Whetten, 1981, 1987). Linney and Wandersman (1991) distinguished between short-term (immediate results) and long-term (system change/reform) programmatic effects, but as few studies have addressed long-term effects, the ultimate indicators may reèect a coalition’s attainment of its mission, goals and objectives (Butterfoss et al., 1993). Rogers et al. (1993) employed the ‘intermediary’ measures of satisfaction, commitment and efécacy in an American study, while El Ansari (1999a) in a study conducted in South Africa expanded on those three intermediary variables and added three more indicators, namely activity, educational activity and outcome effectiveness. Although both authors utilized such intermediary variables as proxies or ‘precursors’ of
Empowering healthcare workers in Africa 235 accomplishment and impact, a better or higher level indicator of programme success may be that the intervention renders the community or the partner organization more competent to address its current health problems (Hawe et al., 1997). On the other hand, because of the empowerment aspects of health-promotion projects, they are required to be evaluated as they proceed (Macdonald, 1998), especially as many collaborative efforts may undertake multiple interventions staggered in time (Kreuter et al., 2000).The measures must be sensitive to changes in the environment—intermediate outcomes—that may affect changes in ultimate health and social outcomes (Francisco et al., 1993). Hence practitioners will need to make difécult choices among the appropriate indicators with which to gauge success (El Ansari, 1994), and although the choice of outcomes can create dilemmas (Caplan et al., 1992), ‘quick wins’ might be necessary to increase motivation, pride and credibility (Brown, 1984; Hord, 1986). A narrower focus may be more likely to yield results, but too narrow a focus can lead to successful but essentially useless accomplishments (Kreuter et al., 2000). Chalmers (1995) cited Stephen Evans (medical statistician) as saying: ‘it is better to measure imprecisely that which is relevant, than to measure precisely that which is irrelevant’. However, in many instances, consortium and coalitions are part of broader interventions that may have achieved a measured health status or health system change (Kreuter et al., 2000). Process, outcome and impact measures (Francisco et al., 1993) all need be included in the monitoring and evaluation of community coalitions (Fawcett, 1990, 1991). After a coalition is formed and gets off the ground, ‘coalition success can be measured in terms of its goals and longevity’ (Staggenborg, 1986). However, no more than 50% of partnerships succeed and up to 80% do not meet the expectations of their architects (Kazemek, 1991).The many dimensions that are associated with effectiveness and satisfaction indicate that such alliances are fragile (Kanter, 1989; Waddock & Bannister, 1991). Partnerships frequently include the involvement of their target communities in identifying their health needs, in priority setting and in planning and evaluating services. An important challenge is the unequal power relationships that shape access to information, decision making and funding (Radford et al., 1997). Central to the notion of collaboration is the concept of shared power (Gray, 1989), and the struggle for participation is one of the democratization of decision making (Segall, 1983; Zakus & Lysack, 1998). However, neither power nor control over policy is usually abandoned by those who have it (Radford et al., 1997), and of 224 projects assessed in a World Bank exercise, only four documented the presence of beneéciary decisionmaking power in the project design (World Bank, 1998; Johnston & Stout, 1999). One way to address and level off the power issues inherent in partnerships is the dimension of enhancing community capacity. Collaborative problem solving develops human capacity and community leadership as participation builds the knowledge and skills of traditionally disenfranchised groups (Clark et al., 1993). Such increased problem-solving capacities can strengthen the community’s ability to interact with more powerful entities (Clark et al., 1993), and can contribute to the ‘competent community’ (Iscoe, 1974; Cottrel, 1976, 1977; Eng & Parker, 1994).
236 Walid El Ansari & Ceri J. Phillips The context Although South Africa is an upper middle-income economy with a per capita GDP of some US$3000, the majority of South Africans live in poverty (Carter & May, 1999) and basic health indices compare poorly with other upper middleincome countries. Exploitation and displacement of ‘black’ people took place under Dutch and British colonization and continued in independence and apartheid, ever conéning more and more blacks into smaller and smaller areas (Aégbo et al., 1986). Half the total population were living below the poverty line in 1991 (Patel, 1993); over half of the ‘black’ rural people are poor and account for three-quarters of poor households in South Africa (May et al., 1995). Apartheid has systematically underdeveloped and deprived the disadvantaged people of this country and resulted in severe inequities.The health system has been fragmented for ideological reasons and, until recently, there were 14 departments of health and four provincial administrations. Centrally there were four departments of health, one for each racial group, which were later combined (National Progressive Primary Health Care Network, c. 1994). Roughly 40% of births are properly supervised, 65% of under-twos are fully immunized (National Progressive Primary Health Care Network, c. 1994), and about 16% of newborns are of low birth weight with malnutrition present in 30% of children (Department of Health, 1995a, 1995b, 1996). Two case studies of partnership workings from South Africa are used to develop a model for empowering healthcare workers through multi-agency collaborative ventures. The cases have educational goals and are aimed at multidisciplinary community-based education for the health and allied professions with a focus on public health principles, population philosophy and community interventions.The érst example—the South African community partnerships—is seven partnerships located throughout South Africa.The second example is a joint collaborative venture between éve South African universities for the delivery of collective and mutual public health programmes. South African community partnerships: collaboration between the training institutions, health services and communities In South Africa the imbalance between specialty care and primary care was making primary care less accessible in communities. In the early 1990s, the W.K. Kellogg Foundation was trying something really different: the Community Partnerships with Health Professions Education Initiative (CPHPE). The initiatives were designed to stimulate a sustained increase in the number of students choosing to enter primary care.The thinking was that the students’ choices were inèuenced by the curriculum, by institutional and professional culture and values, by practical training experiences, and by the incentives for faculty. Since health professional education is an apprenticeship—one learns from what one sees—faculty practice had to model the desired learning for the students and simultaneously promote change
Empowering healthcare workers in Africa 237 among the academicians. The initiatives leveraged institutional change from the outside, through partnership with the beneéciary communities who were stakeholders in health professions education because they needed more primary care practitioners. The partnerships adopted a community development approach in which primary healthcare was being delivered through joint working, in order to inèuence the way health professions are educated to become more community responsive. The target communities were consulted from the inception and new academiccommunity primary care centres were started, where service, teaching and community development were amalgamated. Community–institutional partnership boards, comprising 50% community membership, had oversight of the partnerships. The objective was to promote community-responsive research, shaped by questions from the communities, against a legacy of the institutions doing business in established ways. The programme aimed to expand the experiences and contacts students had during their training to enhance the appeal of primary care practice in communities. Hence, leadership development, communications and networking were employed by the partners to advance the initiatives’ goals. Some of the indicators employed were the extent of the community involvement in admission decisions at the university as well as the extent of institutional reallocated money in order to support the CPHPE model of training. As a result this community-based training resulted in additional programmes for communities: patient education programmes, health fairs, and the mentoring of public school students. The partnerships were collaborative initiatives between health service providers, academic medical and nursing training institutions and communities and their civic organizations (MUCPP, c. 1995). It was clear from the beginning that trust would have to be developed prior to the establishment of the partnerships. This process was inevitably slow and required a spirit of mutual respect, commitment to a common task and sensitization to the needs of the various partners.The aim was exploring the ideals of the partners, sharing a common vision leading to a contract, and developing a common identity. This process of building working relationships based on trust was evolutionary, with new groups representing different community segments approaching the partnerships with a desire to become involved. It became apparent that involvement of the community was one of the strong assets of the programme and that this commitment was one of the major building blocks in its success. The outcomes were a series of activities including the training of health students and health workers, bursaries, the establishment of a community college, youth health desks, clean-up campaigns, job-creation schemes, career preparation, bricklaying and sewing projects. Thusano School of Public Health: a consortium of public health schools The Thusano School of Public Health (TSPH), previously known as the Transvaal School of Public Health, was initiated by a group of concerned and dedicated public
238 Walid El Ansari & Ceri J. Phillips health practitioners in 1991. The school was formed as a partnership to address the health needs identiéed in the new public health agenda introduced in South Africa at the time (TSPH, 1999).The school has éve current partners, and aims to utilize the resources and expertise to develop public health in the new South Africa in a comprehensive and multidisciplinary manner. The TSPH has facilitated communication between universities, public health training institutions, health services and the communities, resulting in reciprocal benefit for the participant institutions from the active and functional interaction. The objectives of the initiative were: to provide èexible, multidisciplinary and multisectoral public health learning opportunities for individuals and institutions whose work impacts on public health; to promote suitable public health research and consultation to improve and maintain peoples’ health; to provide better access to available public health expertise; and to liaise with institutions involved in public health training in order to develop financing strategies and accreditation processes. Through this joint effort the partner institutions were to contribute to the development of the human resource capacity of the health sector. Accordingly, service-driven short courses for senior health managers were implemented along with other skills-based programmes engineered with a primary healthcare orientation. Health practitioners, from a number of different disciplines, and middle managers attended these sessions. Moreover, a modular Masters in Public Health degree, pertinent to the needs of the South African people and the new health system, was developed through a process of wide consultation, drawing on expertise from participating institutions and the health services. However, owing to legislation, accreditation and cross-funding problems this degree was introduced by only three of the partner institutions, and not as a joint venture as had previously been envisaged. Membership of the consortium remains dynamic with a number of tertiary institutions having expressed interest in joining or collaborating with the consortium during the past year. Apartheid policies had created a situation in which mutual understanding between race groups and communities was lacking. Some of the universities involved in the venture—historically ‘white’ and scientiécally and technologically advanced institutions—were now in partnership with the previously ‘disadvantaged’ universities.The past discriminatory policies of the ‘white’ institutions had excluded ‘black’ students and the language of tuition was predominantly Afrikaans, which in the case of most ‘black’ students coming from disadvantaged schools was their third language. As a result of the initiative, these legacies have been rectified. However, the previously ‘disadvantaged’ universities require time to develop their faculty and undertake staff development programmes before they can meaningfully contribute to such an educational partnership.Therefore, various ways to allow for the development of capacity at the partner institutions and for addressing some of the inequities between the institutions have also been introduced.There is no place for institutional competition and rivalry in a truly collaborative effort and hence advocating and lobbying academicians in addition to a strong sense of ownership might be required to get more institutional commitment at all administrative levels.
Empowering healthcare workers in Africa 239 The historical realities of South Africa will, in all probability, need time to dissolve completely before the partnerships created can be truly functional. Development of the model These partnership case studies offer insights into the areas that play significant roles in partnership effectiveness. If coalitions have unrealized potential to change health status/health systems, an important task is to understand where and how the collaborative process fails to connect with desired outcomes (Kreuter et al., 2000). The intrinsic (El Ansari, 1998d) and extrinsic (El Ansari, 1999b) variables that could inèuence partnership functioning are numerous, diverse and multiple. Figure 1 illustrates a conceptual framework for understanding partnership functioning. These groups of factors are all critical to a successful partnership; each group is essential but not sufécient for effectiveness, and the fabric of the variables is intricately interlaced and interacting rendering the variables difécult to isolate (El Ansari, 1999a, 1999c). A systematic overview is given in Figure 1 of the myriad features, which address personnel factors and barriers; organizational factors and barriers; human and personal traits; power-related factors; time factors; and outcomes.These categories and characteristics can enable coalitions to fulél their goals, regardless of the scope, complexity of purpose or method of formation (Sink & Stowers, 1989). Strengths and limitations of the model The model given in Figure 1 captures most of the dimensions involved in partnership working. It was developed from modiécations and expansions of earlier models developed by Rogers et al. (1993) and Gottlieb et al. (1993), both building on the prior work of a group of authors (Wandersman, 1984; Prestby & Wandersman, 1985; Goodman & Steckler, 1989; Minnesota Department of Health, 1990; Perkins et al., 1990; Florin et al., 1992). Other inputs into the model were adapted from questionnaires used by the donor body (WKKF, 1994) for evaluation of the CPHPE in the USA (Michigan State University, Survey Research Division of the Institute for Public Policy and Social Research, 1994; made available through Harris D, personal communication). The strengths of the model are threefold: operational, technical, and conceptual. Operationally, the strength of the model is in its comprehensiveness, its adaptability to multiple-stakeholder initiatives and its applicability in different settings and countries. For example, Rogers et al. (1993) surveyed tobacco control coalitions in California, USA and Gottlieb et al. (1993) examined 50 state and local coalitions across the USA. An expanded version of the model has been employed alongside an accompanying questionnaire in a study of 668 participants in South Africa, with high reliability (El Ansari, 1999a) (data not presented).Technically, the strengths are that the model provides a framework for evaluation and illustrates
Organisational Factors
Personnel Factors Expertise: proposal writing, administrative, managerial/organisational, entrepreneurial Experience: of joint working and particularly on partnership basis Operational Understanding: how members are appointed, how committees are formed Beneéts: gaining of skills, knowing more agencies, reaching target beneéciaries Costs: time, effort, in kind resources, opportunity costs, psychological costs Beneéts/ Costs ratio: ratio of the beneéts to the costs of participating; is it worth? Sense of Ownership: feeling that no outsiders control the partnership Role Consensus: clarity of roles, responsibility, duties Satisfaction Resource Allocation: how are funds distributed in the partnership?
Rules & Procedures: mission, by laws, operating principles Community Representation: of most sectors, agencies, constituencies, community organizations Communication Quality & Mechanisms: written, verbal, channels of dissemination Interaction: dominant groups, assumption of leadership, political considerations Decision making: participation in and inèuence of decisions Management Capabilities: public speaking, organizing meetings, minutes, democratic consensus Flow of Information: regular, relevant, informative, comfortable and timely? Leadership Capabilities: social, political, administrative, delegative Organisational Barriers
Personnel Barriers
Competing Priorities: vision of the partnership agreed upon by all stakeholders? Funds & Fund Raising: sufécient funds? Duration of funding period, sustainability Goal Setting & Decision Making: democratic, consensus, dominated? Co-ordination & Communication: overlaps, duplication, fragmentation, ‘bad timing’ Credit For Activities: competition between initiating agency and the partnership Assumption of Leadership: by consensus, any power struggles? Stakeholder Differences: philosophy, structure, énancial rules or service areas Lack of Participation: low participatory quality, low morale, boycotting Public relations & media: are the partnerships receiving attention?
Member & Staff Priorities: of individual agencies in relation to those of the partnership Expertise: are the required skills available in the participating constituencies? Availability: for meetings, projects and programmes, activities Turnover: new faces welcomed but require clariécation and updating Interest: over a long time period – how can member interest be sustained? Interest: in general partnership activities
Other Factors Power-Related Factors Power Disparities: rivalry, pressure tactics and groups, non-transparency Culture of the agencies: will determine the values of stakeholders Vision: required early, collective, acts as guiding beacon for mission & constitution Accountability: multiple agencies, voluntary participation, accountability not clear Transparency: critical for successful at all stages, related to honesty Change Management: partnerships usually promote change Group dynamics & interaction: partnership’s asset is teamwork Stakeholder Tensions: grievance mechanisms, problem solving/ conèict resolution skills partnerships
Intermediary Measures
Scope of Partnership: health is seldom a priority – community development appealing Number of Partners: obstacles increase with increased stakeholders Number of Problems: is the partnership too broad in focus, too ambitious Simplicity of language: minimal technical jargon, ‘plain’ English Procedural delays: initial énancial constraints, éscal obstacles between agencies etc Timeframes/ funding cycles: objectives chronologically congruent with funding period? Sustainability: need to be thought of early, secondment of posts, alternative funding Institutionalisation: routinisation of partnership operations in participating agencies Human Factors: open-mindedness, negotiating skills, tolerance, patience, persistence Personal Traits: conédence, good relationships, respect, sensitivity Motivation: what motivates real people?
Satisfaction & Commitment Effectiveness & Outcome Efécacy Activity & Educational Activity Accomplishment Impact Sustainability
FIG U R E 1. Understanding partnerships: a conceptual framework Source El Ansari (1999c) modiéed from Rogers et al. (1993) and Gottlieb et al. (1993)
Empowering healthcare workers in Africa 241 the programme’s theory of change, showing how the initial ‘predictor’ variables and barriers connect to form ‘intermediary’ variables and outcomes that a programme is trying to achieve. As such the model can also become a tool for learning: the power of visual representations rather than listings provides effective learning instruments; it ensures that the programme’s process is not overlooked; and it enhances the process of learning through evaluation Harvard Family Research Project (HFRP). Conceptually, the strength of the model is that it assumes that high levels of coalition participation would lead to more effective interventions; that certain structural characteristics need to be present in coalitions in order for them to function effectively; and that attention to operational parameters was central to coalition viability (Rogers et al., 1993).The model also takes into consideration the game theorists’ emphasis on a coalition’s payoffs (outcome achievement); the social psychologists’ emphasis on resources; and the political scientists’ emphasis on importance of ideology similarity in coalitions (Murnighan, 1978; Zapka et al., 1992). In addition, the model deals with the barriers that must be addressed by every coalition: barriers of organization, of attitude, of vision and of ignorance (Hagebak, 1982; Allensworth and Patton 1990). However, logic models also have limitations. First, an over-simplistic model is not of much operative or evaluative value and, alternatively, a model that captures the various dimensions may become duly cumbersome for the busy practitioner. Yet, models are useful for facilitating the overview of factors that operate and interact, whether in convergence or divergence. As guidebooks are useful for travellers embarking on a journey, they do not preclude that the traveller ‘looks’ away from the guide to see what is around. Similarly, the model we pose facilitates the understanding of the critical variables by providing a ‘conceptual map’, but practitioners and administrators need to ‘look’ to their unique partnership’s landscape in order to identify the variables that exert more leverage in their coalition arrangements. Second, the succession of events is rarely linear as seen in models and, especially in partnerships, recursive modes are frequent with the addition of new partners or indeed the change of representation and the appearance of ‘new faces’. Third, cause-and-effect relationships are extremely arduous to verify in partnership work, and especially where other ‘background’ interventions are also taking place. Fourth, limitations also arise when self-reported perceptions of stakeholders are utilized for verifying the pathways that a model suggests. Here individual objective measures of the variables, barriers and outcomes or measurements from other partnerships in different localities and countries could be useful in conérming or refuting the suggested pathways. Applying the model As the conceptual framework had been derived from empirical as well as literature sources, some examples illustrated below aid in the clarification as well as the application of the model to the South African case studies. One example per box is employed to exemplify the factor under operation (e.g. personnel barriers,
242 Walid El Ansari & Ceri J. Phillips organizational factors), and the fact that the factors and barriers are intricately intertwined. Personnel factors (beneéts, costs and beneét/cost ratio) If participation is such a good thing, why do more people not participate? It is worth noting that rewards for community participants are largely philosophical, emotional and symbolic as compared with those for health professionals and managers, for whom participation often has tangible professional and career advantages. An investigation on the South African community partnerships (El Ansari, 1999a) (data not presented) reported on three comparison groups: those not very involved, those moderately involved, and those very involved in the partnerships. There was a gradient that increased as one moved from the less involved to the very involved participants, i.e. as involvement increases, a more favourable beneéts-to-costs ratio was perceived. This gradient provided a ‘dose–response’ support for the relation between involvement and perception of favourable beneéts-to-costs ratio. Personnel barriers (member priorities, turnover and interest) Professional staff priorities and turnover, together with volunteer availability and interest, were common barriers for coalitions to address. El Ansari (1999a) in an examination of the South African partnerships (data not presented) reported that professional staff priorities and volunteer availability and interests were perceived to be a major problem by over 30% of the sample across the partnerships under investigation (n = 668).The barriers of staff availability, conèicting priorities and turnover have the potential to cause interpersonal tension among agency representatives, staff burnout, weaknesses in programme delivery and a lack of continuity in representation. Organizational factors (rules and procedures) The range of formalization activities in the South African community partnerships spanned different stages: from formalizing agreements between the stakeholders to drafting and later signing a constitution (one partnership had its constitution signed 3.5 years down the road in a éve-year funding cycle).This seemed appropriate but the earlier formalization of such a charter would have been binding for the stakeholders. With earlier responsibility and commitment from the participating agencies and a wider margin of the funding cycle remaining, planning and implementation of the partnership’s programmes could have received more attention.
Empowering healthcare workers in Africa 243 Organizational barriers (goal setting and decision making) Consultation was lacking regarding the élling of posts and the erection of buildings, power tactics and self-interests. For instance, some community participants were unclear whether it was the partnership’s collective board or the partnership’s director that was the source of decisions. One of the reasons behind the lack of consultation included the ‘do your thing’ culture that may unwittingly sometimes be nurtured in partnerships in the face of heavy workloads and tight time frames or simple organizational dysfunction leading to lack of teamwork. Another reason was the professionals’ cautious appreciation of the community’s indigenous abilities and skills and the perception that community members lack the necessary knowledge. Decision making was further hampered by unequal interactions in the meetings, the language and technical jargon that was sometimes used between the members and stakeholder groups, which inhibited attendance, the hidden agendas, and the turnover of members where new faces frequently needed socialization and updating. Power-related factors (power disparities) The academic institutions were seen to be in power, especially in that the partnerships’ constitutions supported the university for énancial administration. All énances from the donor body to the partnerships and out of the partnerships were administered through the academic partner. On the one hand, if finances were channelled to the partnerships via their university component they automatically became tax exempt, which increased the énal yield to the individual partnership in terms of dollars received. Besides, in this manner a sophisticated accountancy log could be kept, as the university already had the administrative expertise to do so. The énances were then kept in a university bank account. However, it was not readily apparent to whom and where the interest on such large sums (millions of South African Rands) accrued. On the other hand, this process helped reinforce a view that seemed well entrenched within the community: again, the project was controlled by the academics. A joint bank account needed be held and to be accessible to all parties, as opposed to all énancial transactions getting university agreement érst before being cashed.This process might have perpetuated a feeling of inequality on behalf of the community members: although they comprise 50% of the Board, university clearance would always be needed. Was this a real community partnership? Thus, even quite unintentionally, community participation usually ends by consolidating the power of professionals, rather than achieving the ideal of broad-based local involvement. Other factors (procedural delays) Some of the community partnerships had an initial time lag of about a year to develop more comprehensive proposals before they qualiéed for full funding.This
244 Walid El Ansari & Ceri J. Phillips ‘latent’ period, when present, excited an initial wave of participation which frequently and quickly withered away, adding more delay to the already slow-moving process of harnessing the participant agencies in one direction for synergism and impact. Elsewhere (El Ansari, 1994; El Ansari & Phillips, 1998), the researchers have cautioned against the effects of time lags and delays and ‘frozen’ periods during the initial stages of funding on programme initiation and the maintenance of the initial drive of eager community members and organizations, who needed something they could ‘get their teeth into’. Discussion The links between geography, demography, environment, public health and death rates are being slowly uncovered, and a better understanding of the linkages between physical environment and social outcomes is being realized. Despite great achievements in medical science and technology, considerable challenges still persist.The increasing disparity in access to healthcare and the growing population of the poor, the rapid environmental changes and growing emergencies resulting from internal conflicts and civil wars and the inability of technology to face epidemics are all examples of problems which indicate that solutions will inevitably lie in multisectoral and multidisciplinary efforts and initiatives. The complex and intractable nature of problems related to health, poverty and the environment in developing areas of the world have frequently led to collaborative efforts to solve them (Clark et al., 1993).The World Bank has produced ‘Consultations with the Poor’, a series of participatory studies by local organizations to listen to the voices of poor people in 60 countries (World Bank 1999a; Narayan et al., 2000). During the last few decades, the concept of ‘partnership’ has become increasingly compelling in national health, social and educational policies. Governments have learned that downsizing multisectoral perspectives can jeopardize otherwise well-designed interventions. In addition, coalitions with community representation are seen to be more understanding and responsive to ‘true’ community needs (Schlaff, 1991).The rationale for collaborative mechanisms varies but, generally, is captured by the assumption that community participation mutually beneéts both the community and the programme (Kreuter et al., 2000). As highlighted in the two cases studies of South African partnerships, when individuals and groups joined together to address common concerns, they increase their potential to formulate and carry through intervention strategies (Kahn, 1970). Through concerted joint efforts, the South African partnerships for health professions education were able to initiate a wide variety of community-responsive educational projects and courses as well as vocational and training programmes. Similarly, the Thusano collaboration of educational tertiary institutions has started various short course programmes and health managers’ courses, which have produced reciprocal benefit from the active and functional interaction between participants. The case studies have illustrated that mutual support, increased communication and interaction among organizations involved in a coalition is likely
Empowering healthcare workers in Africa 245 to decrease isolation and facilitate greater awareness of trends that affect them, as advocated by Saranson and Lorenz (1980). Consortia, collaboratives and coalitions between multiple partners and stakeholders as vehicles of programme delivery have come to the fore at the same time as the increased potential of coalitions to inèuence policy making in a positive way is being discovered. However, collaboration itself has been shown to have many built-in constraints (Bloxham, 1996, 1997) and is not without its down-side (Cheadle et al., 1997).The complexity of each partner needs to be recognized, as each partner is not a homogenous entity. Many of them may not see a partnership as a priority. People or departments may not be too anxious to spend their limited time and resources in partnership-development activities. One therefore should not assume that people and institutions are ready and waiting to be engaged in the process. They are fully occupied with their own and, in their own opinion, more relevant activities. This applies equally to all the partners and not just the community. For example, one of the many challenges faced by the South African partnerships for health professions education was the issue of contributing time, effort and already stretched resources to the initiative. Here, the academic staff involved in the effort had numerous teaching commitments whereas the health service partners had serious workloads and always needed clearance in order to attend and contribute to the partnership’s meetings and activities. Similarly, for the community, their daily activities and breadwinning were more of a priority than the issue of health professions education. Within this realm, Radford et al. (1997) reported that if participation also entails accepting responsibility for any decisions made, then how feasible or even desirable this would be from the point of view of community members is questionable. It may not be possible simply to assume that members of communities are waiting to become fully involved. They may welcome consultation but without wanting to assume responsibility for énal decision making. Dryfoss (1994) noted that ‘collaborative plans are difécult to achieve because of the different characteristics of the agencies involved’, with different forms of democratic control, bureaucratic systems, complexity of planning tasks and professional traditions. Collaboration hence requires a ‘give-and-take attitude’ among the stakeholders, designed to produce solutions that none of them working independently could achieve.This often kindles a renewed willingness to search for trade-offs that could produce a mutually beneécial solution (Gray, 1989). Green (2000) also drew attention to coalitions, which become unnecessarily large in terms of numbers of partners, or unnecessarily ambitious in their attempt to micromanage the implementation of programmes. Although the addition of more organizations is usually done less for complementary contributions and more for the political value, the complexities rise exponentially.
246 Walid El Ansari & Ceri J. Phillips Conclusion I have a dream. (Martin Luther King, 1963) Partnerships are prominent mechanisms for building local capacities to address health and social concerns (Francisco et al., 1993). They are alliances among different sectors, organizations or constituencies for a common purpose. They maximize the efécient use of resources, lessen the fragmentation of services, enhance relationships and build trust, and raise citizen participation and interests in programme planning (Brown, 1984; Orthoefer et al., 1988). The health sector (Cassels, 1995) has begun to recognize the need for community participation, and the World Bank operations evaluation department observed that most projects include objectives that can only be met through client-responsive services (Heaver, 1988). However, participation by local people in multi-stakeholder health-related activities is difécult to achieve and maintain. Macfarlane et al. (2000) noted that the World Bank publication Better Health for Africa (World Bank, 1999b) recommended the creation of an enabling environmental for health through the involvement of communities. If Partnerships for Health in Africa are to go beyond the rhetoric to make real changes and responses to unmet needs, far-reaching joint working approaches are indispensable. It is important to take stock of existing models and explore new forms of intersectoral and multisectoral cooperation to ensure an equitable change of views, information and knowledge (Kickbush, 2000). Thus there is a critical need for partners and stakeholders to adapt a ‘whole system’ approach to understanding the complexity of the modern organization of collaborative efforts. If health is—as Radford and colleagues (1997) have noted—‘everyone’s business’, then partners are required to have an increased awareness of the diverse dimensions, the multifaceted nature, the necessary capacities and expertise, roles, rules, procedures and responsibilities and vision and expectations for attaining this ambitious task. This paper has charted the use of collaboration and partnerships, and by highlighting two examples of joint working in multidisciplinary health professions’ education in South Africa, has addressed many dimensions of partnership functioning. It has illustrated the strategic levels of partnerships and the effects of organization and structure. It has also reviewed the stage of development and the partnership’s membership, and addressed the obstacles encountered when measuring partnership effectiveness. In doing so it has brought attention to the multifaceted nature of collaborative endeavours and multisectoral activities, in which the importance of community involvement and participation for health are critical. It has brought awareness of the complicated nature of the partnership jigsaw in developing the model. In parallel, it has also highlighted the effects of timeframes and funding cycles as well as the importance of the human and personal traits of partnership administrators and champions. Addressing community health issues and educating health professions students at the same time present philosophical and logistical challenges. Similarly, building a functional educational public health consortium of educational institutions with different cultures is an arduous task.To
Empowering healthcare workers in Africa 247 join diverse groups in a working partnership, leaders need to appreciate the interests and dynamics of each and be alert to ways of linking differing perspectives around common interests. Connections among groups are complicated and tenuous, and relationships between the community as aspirations and the universities as institutions and bureaucracies are equally complex. Finding ways to bridge the different perceptions is part of the early work required by partnership leaders. However, building bridges is not something done once and for all but rather an ongoing process and a learning experience. An important point is that the desire to collaborate is not an issue only at a conceptual level: the challenges come at the basic, fundamental and ‘nitty-gritty’ levels.Thus in a èuid environment, cultivating and maintaining connections as well as awareness of the challenges and the dimensions of collaborative working is indispensable for those involved in similar ventures (Carlson & El Ansari, 2000). This paper has proposed a model for joint working that takes into account the multitude of partnership dimensions cited earlier, and discussed its strengths, limitations and applications.With a high desirability for some form of collaborative activity becoming a sine qua non of effective practice, but with remarkably little knowledge about how it works, collaboration is a paradoxical concept (Delaney & Moran, 1991; Delaney, 1994). As alliances and coalitions have been advocated as means of solving problems in society (Stoner, 1982), and there is evidence in support of their impact on policy (Goldston, 1991), robust models are necessary that could improve our understanding as well as act as a guide for evaluators (El Ansari & Phillips, 2001). Should coalition administrators revisit their collaborative efforts periodically and chart their perceptions and challenges systematically against the insights that such models provide, improvements can be made. As joint working requires effort and is time-consuming, models that address maintenance variables need to be in place so that practitioners can focus on outcomes and impacts. Otherwise, as Green (2000) has noticed: ‘so much goes into maintaining a coalition that little remains for the programme’. References Aégbo, A. E., Ayandele, E. A., Gavin, R. J., Omer-Cooper, J.D. & Palmer, R. (1986) The Making of Modern Africa (Harlow, Longman). Allensworth, D. D. & Patton, W. (1990) Promoting school health through coalition building. Eta Sigma Monograph Series, 7, pp. 1–89. Balcazar, F. E., Seekins, T., Fawcett, S. B., & Hopkins, B. L. (1990) Empowering people with physical disabilities through advocacy skills training. American Journal of Community Psychology, 18(2), pp. 281–296. Block, P. (1993) Stewardship: Choosing Service over Self-interest (San Francisco, Berrett-Koehler). Bloxham, S. (1996) A case study of interagency collaboration in the health education and promotion of young people’s sexual health. Health Education Journal, 55, pp. 389–403. Bloxham, S. (1997) The contribution of interagency collaboration to the promotion of young people’s sexual health. Health Education Research: Theory & Practice, 12(1), pp. 91–101. Bracht, N. & Kingsbury, L. (1990) Community organisation principles in health promotion: a éve-stage model. In: Bracht, N. (ed.) Health Promotion at the Community Level (Newbury Park, CA, Sage).
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