Viola Cassetti is an anthropologist and public health researcher at the School of Health and Related Research, University of Sheffield.
Place-based partnership working takes on added importance with the asset approach. Silos and agency boundaries get in the way of people-centred outcomes and community building.
In recent years the emphasis on the need for new strategies and approaches to tackle inequalities has increased. For over a decade across Europe there has been an increasing interest in Asset-Based Approaches (ABAs) as a potential solution to inequalities. A lot has been published and researched on the topic of assets as positive resources for health and an increasing number of projects and interventions have emerged under the label of ABAs; however, there are still questions around how to adopt these approaches. A key feature of ABAs centres around relationships in the wider and encompassing sense. ABAs are about strengthening meaningful relationships both between individual members living in a community and between organisations working locally. Adopting an asset-based way of working means that different stakeholders come together, recognising each other’s skills and capacities; valuing each other and the resources available locally; and work together to support people-centred actions to promote health and tackle its social determinants. As Foot and Hopkins (2010) argued in their publication in 2010: “Place-based partnership working takes on added importance with the asset approach.” However, “silos and agency boundaries get in the way of people-centred outcomes and community building.”
In fact, there is increasing evidence that single-sector actions alone cannot achieve the expected improvement in health and its determinants nor the desired reduction of health inequalities (Bertram et al 2018; WHO Europe 2019) and a growing body of literature stresses the need for working collaboratively across sectors. However, even though partnership work has been encouraged and evidence of its importance has increased; boundaries (visible and invisible) between agencies tend to persist, making intersectoral work a challenge for many.
1. What are partnerships and why they can be important
Partnerships can be seen as dynamic encounters, where stakeholders representing different institutions with different knowledge and values meet to get to know each other and act together for common purposes (Aveling & Jovchelovitch 2014). Working in partnerships as a key to promote health for all has been at the core of holistic approaches to health over recent decades (Jones and Barry 2011a). A growing body of literature has placed emphasis on the need to work collaboratively across sectors, to address the social determinants of health. In most cases these are beyond the reach and scope of the health sector alone.
2. Partnerships are about relationships
As dynamic encounters, there can be different types of partnerships and different types of stakeholders in a partnership. With ABAs partnerships are about relationships. As with any relationship time is needed to familiarise with each other and build trust. In fact, a key element for stakeholders to make intersectoral work successfully is to create a positive synergy within the partnerships. In other words, to create the conditions to allow the different knowledge, strengths, ideas, values and approaches of each stakeholder to merge to achieve the desired (shared) goal (Jones and Barry 2011b). Having a shared goal and continuously building trust among partnership stakeholders is fundamental (Corbin et al 2017), to develop strong relationships and build cohesion and collaboration (Woulfe et al 2010). However, partnerships are also a complex structure of relationships and being able to coordinate these effectively is equally important (Jones and Barry 2011b; Stolp et al 2017).
3. What can a partnership to promote health look like?
Examples of partnerships to promote health are varied across the world. Partnerships can function as a unit in different ways because of the context and relationships through which they are formed and because of the scope and purpose they have. There can be different activities which can emerge from working across sectors, as well as different forms to organise the work across sectors.
An example of an activity which can result from intersectoral work, which has recently been attracting rising interest in some countries across Europe, can be found in what has been termed ‘social prescribing’ (Bikerdike et al 2017; Chatterjee et al 2018; López et al 2018). Social prescribing centres around the idea of prescribing community assets, generally in the form of group activities, to healthcare patients as a complementary or alternative source of support for health and wellbeing. Social prescribing interventions embody the values of an asset-based approach to health as a way to tackle individual and intermediate health determinants. They are underpinned by intersectoral work in local communities to create alliances with non-health sectors, raise awareness on the available assets and ensure appropriate follow-up is in place for all those involved.
An example of a form to organise intersectoral work towards tackling the intermediate social determinants of health can be found in the creation of local intersectoral health alliances. In Spain, for instance, the National Health Promotion and Prevention Strategy centres around collaborative work and encourages the creation of local health alliances where different sectors come together to jointly plan actions and policies to promote health and wellbeing in local areas or municipalities (see the case study box for more details). In some regions of Spain a similar process has been promoted as part of the local healthy cities network. It’s the case of XarxaSalut (literally: health network) in the Valencian Community, a network of healthy cities. This promotes the establishment of local intersectoral alliances to develop community interventions to promote health and tackle its social determinants (Conselleria de Sanitat Universal i Salut Pública 2018).
Case study: Local intersectoral alliances in Spain
4. Common challenges in working in partnership
Intersectoral work is challenging as current governance structures in many countries across the world tend to work in silos, lacking support and policies which could enable a more intersectoral approach to thrive. It is important to ensure intersectoral work is supported by collaboration at both horizontal and vertical level. Even though at a more horizontal level relationships between partners are established and work well, if the ‘vertical’ system does not foster intersectoral work but forces each sector to separately, this can make collaborations difficult (Rantala et al 2014). Therefore, fostering shared planning and good communication across the ‘vertical’ level can facilitate the work of a partnership and limit the risk that what is decided by a partnership at government level does not translate into the work of frontline staff or vice versa (Hunter and Perkins 2012).
Although having a shared mission is central in any effective partnership (Corbin et al 2017), there are other factors which can enable or hinder intersectoral work. These include having time to dedicate to the partnership; the establishment of trustworthy relationships; good communication between members; and the adoption of inclusive and participatory approaches (WHO Europe 2015). Finally, although partnership work has been shown to be key in health promotion practices (Corbin 2017), the lack of evaluation of the benefits of intersectoral approaches for other sectors can make it a challenge for the non-health sector to find partnership work appealing and helpful for their own work.
5. Asset-based and place-based partnerships: working towards a common goal to support healthy communities
Adopting an ABA is about encouraging local people and communities to take control over their own health and make use of their own assets. This approach needs wider system changes to accompany or enable the resulting processes. Creating asset-based and place-based partnerships are key to enhancing integrated health promotion strategies in a collective effort to reduce health inequalities.
What elements should be taken into account to create asset-based and place-based partnerships?
- Putting people and communities at the centre of intersectoral health actions: A holistic view of people and communities, their health and determinants should be at the base of any change towards creating the conditions to favour intersectoral work. Participatory approaches such as co-production and co-creation can support the development of partnerships. This should include the views and voices of the people and communities whose health is to be promoted.
- Taking into account the local context: Each place has its own histories and dynamics and these will influence how a partnership is formed, who participates in it and how it relates to the wider community. It is important to know these previous histories as these are part of the local knowledge, expertise and context which a partnership can build upon.
- Creating inclusive partnerships based on trustworthy relations: Partnerships should be inclusive. This depends not only on the opportunities for involvement but also on the perception of the self and the ‘others’ in a partnership. For instance, when the ‘other’ is seen as vulnerable and in need and the self is seen as the expert capable of providing what the other is lacking there is a risk to create an imbalanced power relationship between the subjects (Aveling & Jovchelovitch 2014). In an inclusive and equal partnership, each stakeholder should be considered as an expert in his or her field and the knowledge which that person brings to the table should be valued as such. It is important to include a diversity of members to better represent the membership of the community whose health the partnership aims to improve (Woulfe et al 2010). By welcoming differences in expertise and perspectives stakeholders can work together to develop common thinking and shared ways forward while developing interventions which reflect the social contexts where they are to be implemented (Aveling & Jovchelovitch 2014; Woulfe et al 2010).
- Allowing time to develop those cross-sectoral relationships: Stakeholders from different sectors should participate equally. Time is needed to develop these cross-sector relationships; to identify common goals; to develop trust and collaborative leadership between partnership members; and recognise each other’s strengths and capacities. Intersectoral work can become a way to build social capital and work adopting an assets approach.
- Communicating as equals and speaking a common ‘language’: Most often there is an assumption that all stakeholders in a partnership speak a ‘common language’. However, a shared understanding of an issue and developing shared goals and visions takes time to develop. This can be because stakeholders do not share a ‘common language’ and understanding of reality and terms (Aveling & Jovchelovitch 2014). The ways in which communications flows within a partnership can determine the results that can be achieved collectively. Maintaining regular and open communication between members is key (Estacio et al 2017) to ensure everyone can participate (Woulfe et al 2010).
6. What can be done to accelerate partnership work?
A holistic view of people and communities, their health and its determinants should be at the base of any change towards creating the conditions that favour intersectoral work. So, what can be done to accelerate partnership work? Here are some suggestions to inform future actions.
- 1. Moving beyond a ‘silo-outcomes’ approach. If the intervention is intersectoral so should be the results to be achieved. Outcomes should stop being related to only one sector. Mechanisms to support cross-sectoral planning and evaluation can facilitate the work of partnerships.
- 2. Ensuring partnerships are supported and resourced. Such a re-orientation towards implementing effective intersectoral work needs to be endorsed by the wider system with both human and financial resources provided. For example, creating a dedicated health promotion unit and ensuring funds are specifically provided for intersectoral work could support such a re-orientation (McDaid 2018).
- 3. Encouraging anchor institutions to become partners in local health alliances. Health systems at local level, as well as universities or other educational institutions, could take up the role of anchor institutions. They can become central partners in the development of local intersectoral alliances which should be place-based and people-centred. Anchor institutions are institutions with financial capital that are ‘anchored’ in communities, i.e. they are not likely to go away if a crisis come or market trends change. They are generally non-profit organisations, mainly public (such as hospitals, health centres, universities) and are place-based (Cantor et al 2013). Anchor institutions can establish policies to employ locally, source locally, build locally and work collaboratively in partnerships for (ideally) the long term, thus favouring the sustainability of local health initiatives. They can become an important asset in the fight to reduce health inequalities as they become ‘drivers of economic development’ (Democracy Collaborative 2019) and could ensure sustainability and support to the local health initiatives.
- 4. Working collaboratively with the social and voluntary sector. Civil society organisations provide services aimed at improving the health and wellbeing of the people in their communities, as well as tackling the social determinants of health across the life course and should be key stakeholders to engage. Foot and Hopkins (2010) in their initial work on ABAs commented on the role of the third sector as potentially being the leader for this change towards people-centred partnerships informed by an ABA.
- 5. Fostering a Health in All Policies approach. To ensure that activities across different government sectors and levels should take into account the health impact that they can generate. This can act as a leverage for the health system, supporting a re-orientation towards a more people-centre healthcare; moving beyond the biomedical approach to health and to the individual. Together with the increasing financial pressures the risk is focusing towards providing immediate (and temporary) solutions to some of the health issues where the causes are more social than biological.
More than a decade ago Michael Marmot argued that if the determinants of health are social, so should be the solution. How can we expect to tackle the problem of health inequalities working in silos? We need to embrace the same holistic and systemic approach to this challenge as has been proposed for the wider determinants of health. Working in partnerships should be part of that solution.
Local partnerships and COVID-19
When the current COVID-19 pandemic struck across the world, most countries believed that this exceptional situation was going to be a temporary interruption of ‘normal’ life. However, as weeks started passing by, it became clear that the situation was not going to be ‘temporary’ but the public health response was already arriving late.
It has often been said that it is in the times of crisis and hardship that solidarity becomes most visible. And the COVID-19 pandemic has shown that this is indeed the case. During lock-down, people across the world have started getting together, to support their communities. The pandemic showed a rise in local initiatives, where neighbourhoods residents, local institutions and voluntary and community sector organisations got together in some forms of ‘partnership’ to respond to local needs (Rippon et al. 2020), being these supporting the elderly population with food shopping or sewing face masks for workers (Grupo PACAP 2020; Pola García et al. 2020). However, the pandemic has also made visible the widening health inequalities between and within countries, as people in more vulnerable situations or living in less advantaged neighbourhoods have been among those worst hit by COVID-19. Many local initiatives were in fact created to mitigate the impact of this pandemic, providing help and support to those most in need. For instance, according to The Trussel Trust (2020), the number of people using food banks during the pandemic has doubled compared to previous years.
Why are local partnership important in a pandemic?
Today, to protect people’s health and reduce the risks of infection, it is vital to find effective health communication means targeting different population groups. As previous pandemics have shown, combining evidence-based recommendations with local expertise can support people in understanding risks and taking up preventive behaviours (Van den Broucke 2020). Working together across sectors at local level thus takes on an added importance. Members of local partnerships can have a key role in adapting national public health strategies to local contexts and lay knowledge. Local initiatives and partnerships, which have worked to support people’s health during the COVID-19 pandemic, can therefore represent an opportunity to further develop relationships and work together with a common purpose, that of promoting health for all.
However, it is also key to account for the social determinants affecting the health of all, and more importantly, of those in most vulnerable situations. Through engaging residents, community organisations, local governments and policy makers in shared dialogues, local partnerships can play a central role in fostering people and community-centred approaches: they can support communities to identify which health determinants they are being affected by, and to co-create solutions to tackle these, thus enhancing communities’ resilience and their capacities to recover and thrive (Rippon et al., 2020).