Public Health & Multisectoral Collaboration: Where’s the Evidence?

Isolating the effects of collaboration is messy; many of the factors associated with successful multi-sectoral partnerships, such as strong leadership or availability of resources, are difficult to measure and/or also associated with good community health.

Multisectoral collaboration to address community health is foundational to public health practice. Mobilizing and maintaining community-based partnerships across different sectors is one of the ten essential public health services, and accordingly, accrediting bodies such as the Public Health Accreditation Board (PHAB) encourage or require health agencies to pursue community partnerships to address community health issues.1 Policymakers and regulators likewise have instituted policies meant to push health agencies to collaborate on specific health issues such as emergency preparedness and/or on specific services (eg, state policies that require hospitals and health agencies to perform community health assessments together).2–4   

Yet, despite our continued belief in multisectoral collaboration, it is also important to note that the empirical evidence supporting the idea that multisectoral collaboration per se will lead to improvements in community health is fairly limited.5 That is, when we observe sustained improvements in population health outcomes in communities with ongoing multisectoral collaboration, there is surprisingly little evidence that the improvements were due to the effects of collaboration. We know that organizational partnerships can better connect people to needed resources, which has health implications.6 We have evidence that well-functioning community partnerships can lead to improvements in things like care coordination between hospital and community settings, which may lead to improvements in health.6,7 We have also observed short-term improvements in health status in some communities where multisectoral collaboration was occurring.7

But otherwise, the evidence supporting collaboration is decidedly mixed.5 A 2016 study found that expansions in health agencies’ networks of collaborators led to significant improvements in certain health outcomes over a period of sixteen years.8 More recently, another study found evidence that health agency and hospital collaborations are better able to reduce drug-induced mortality when working together in communities where drug use is a concern.9 There is very little else that we can point to as definitive evidence that multisectoral collaboration can improve community health beyond the short-term. Isolating the effects of collaboration is unfortunately messy; many of the factors associated with successful multi-sectoral partnerships, such as strong leadership or availability of resources, are difficult to measure and/or also associated with good community health.10    

Moreover, collaboration is hard. Working together to find common cause and then keeping those efforts going is hard. It requires significant resources, strong leadership, buy-in from participating organizations, not to mention a shared long-term commitment and understanding that collective action will lead to better outcomes for their community’s health.11 Public health leaders must contend with competing organizational interests and viewpoints, distractions that take focus away from continued cooperation, and a general dissatisfaction that can seep into even the best functioning partnerships over a long enough period of time.11,12 Successfully initiating and sustaining positive changes in community health also takes a tremendous amount of time and effort and is not a short-term endeavor.12   

And yet, as public health practitioners, we continue to believe in the power of collaboration despite the lack of empirical evidence that it works to improve community health. Why? After all, our field is supposed to operate based on evidence-based principles. 

Because we know that public health cannot function without collaboration. We know that the variables that influence community health issues are complicated, multifaceted, and largely operate outside of the traditional health care system, but that public health can help facilitate the collective action necessary for addressing these issues.13 We continue to foster multisectoral relationships because some of our most transformational public health successes, such as fluorinated water or seatbelt laws, have happened in non-health sectors and that public health has an obligation to help identify and translate these successes by working with the responsible stakeholders. While we have much to learn about the different factors that facilitate and sustain successful multisectoral collaboration, there is little doubt that such partnerships are integral to how public health works in practice. 

References

  1. Public-Health-Accreditation-Board. Seven Steps of Accreditation. Public Health Accreditation Board. Accessed May 13, 2022. https://phaboard.org/seven-steps-of-accreditation/
  2. Internal Revenue Service. New Requirements for 501c3 Hospitals Under the Affordable Care Act. Internal Revenue Service; 2014. Accessed February 5, 2018. https://www.irs.gov/charities-non-profits/community-health-needs-assessment-for-charitable-hospital-organizations-section-501r3
  3. Ohio Department of Health. Ohio Revised Code—Title [37] XXXVII Health—Safety—Morals— Chapter 3701: Department of Health—3701.981 Completion and submission of assessments and plans. Published online 2019. Accessed December 14, 2022. http://codes. ohio.gov/orc/3701.981
  4. Public Health Emergency Preparedness (PHEP) Cooperative Agreement | CDC. Published March 2, 2023. Accessed March 26, 2023. https://www.cdc.gov/orr/readiness/phep/index.htm
  5. Fichtenberg C, Delva J, Minyard K, Gottlieb LM. Health And Human Services Integration: Generating Sustained Health And Equity Improvements: An overview of collaborations, partnerships, and other integration efforts between health care and social services organizations. Health Aff (Millwood). 2020;39(4):567-573.
  6. Berkowitz SA, Terranova J, Hill C, et al. Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries. Health Aff (Millwood). 2018;37(4):535-542.
  7. Conrad DA, Cave SH, Lucas M, et al. Community care networks: Linking vision to outcomes for community health improvement. Med Care Res Rev. 2003;60(4_suppl):95S-129S.
  8. Mays GP, Mamaril CB, Timsina LR. Preventable death rates fell where communities expanded population health activities through multisector networks. Health Aff (Millwood). 2016;35(11):2005-2013.
  9. Santos T, Lindrooth RC. Nonprofit Hospital Community Benefits: Collaboration With Local Health Departments to Address the Drug Epidemic. Med Care. 2021;59(9):829-835. doi:10.1097/MLR.0000000000001595
  10. Siegel B, Erickson J, Milstein B, Pritchard KE. Multisector partnerships need further development to fulfill aspirations for transforming regional health and well-being. Health Aff (Millwood). 2018;37(1):30-37.
  11. Fawcett S, Schultz J, Watson-Thompson J, Fox M, Bremby R. Peer reviewed: Building multisectoral partnerships for population health and health equity. Prev Chronic Dis. 2010;7(6).
  12. Hearld LR, Alexander JA, Mittler JN. Fostering change within organizational participants of multisectoral health care alliances. Health Care Manage Rev. 2012;37(3):267-279.
  13. Pittman MA. Multisectoral lessons from healthy communities. Prev Chronic Dis. 2010;7(6).

Author Profile

Henry Stabler
Hank Stabler, PhD, is a postdoctoral research student with the UMN Center for Public Health Systems with experience in program evaluation, policy analysis, and mixed methods research. Dr. Stabler’s research interests relate to hospital-community relationships and multisectoral collaboration. He holds a PhD from the University of Minnesota’s Health Services Research, Policy, & Administration program with a focus on Health Policy, and an MPH from the University of Michigan.