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Challenges:

• Achieving systems change is hard work. Systems change or reform takes time, occurs at many levels (e.g., neighborhood, agency, city, county) and represents a fundamental change in orientation toward service delivery. While the language may be confusing, it was equally difficult to determine where reform should begin—integration of services, integration of data, finance reform, or new organizational structures and relationships? A sequential approach to systems change with a clearly defined pathway leading to efficient and effective delivery of preventive services was needed to assist health partnerships. Systems change efforts undertaken by health partnerships lacked access to promising models or best practices that could have been instructive.
• Authentic community involvement is difficult. It was difficult to engage residents “at the table” within predominantly agency-based health partnerships. Each site acknowledged the critical importance of community engagement to achieve systems change, but experienced challenges accommodating grassroots demands and expectations in systems change and policy objectives. Being inclusive of community participation is essential but can also unduly dictate the agenda. Issues such as cultural competency, primary languages spoken, abstract concepts and jargon and meeting locations/time all affected authentic community involvement. There was also tension within health partnerships regarding the methods of resident involvement versus resident-driven approaches to population health improvement. As the HII progressed, the definition of community involvement expanded to reflect the uniqueness of each health partnership.
• Attribution for advances in population health is difficult to determine in community settings. It is difficult to attribute success and failures within population-based collaboratives where simultaneous multiple efforts affect city or countywide health outcomes. TCWF staff, health partnerships and HII evaluators desired greater confidence in perceptions of attribution and accomplishment. In the final analysis, the question became: “What contributions did the health partnership make to observed results?”
• Each health partnership’s lead agency/fiscal agent affected the process and outcomes of grant activities. Accountability to the Foundation, to the lead agency’s board of directors and to the health partnership often placed the lead agency and collaborative members in competition and/or conflict. Issues such as organizational turf and power were played out in most health partnerships. In most cases, the lead agency/fiscal agent seldom assumed an equal partnership role in collaborative efforts -- leading to resentment of the lead agency, disillusionment of health partnership members, competition and/or apathy in seeking additional resources.
• The role and contributions of the local evaluators were often not realized. Each health partnership allocated funds to support a local evaluator and all but one site developed and implemented local evaluation plans. Some local evaluators adapted well to the HII focus while others did not. Some were responsive to health partnership needs; others pursued their own agendas or relied on a skill set not compatible with the health partnership. With few exceptions, the local evaluator was not an asset in the design, implementation and publication of local public opinion surveys.
• Outcomes didn’t always matter. There was general frustration that the health partnerships’ performance and improved outcomes did not always matter to stakeholders. As the work of the HII progressed, it appeared that positive results did not routinely affect policy, inform decisionmaking, impact funding allocations, etc. Conversely, some decisions were made in absence of, or prior to, results being reported. This issue deserves further attention, as each participant in the HII is susceptible to ineffective and inefficient efforts if there is not a commitment to learning and using results -- good or bad. Initiative evaluations must begin with a commitment to using results, and health partnerships must be committed to use these results to inform current efforts and future investments.