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Challenges: 

• Language describing the process and intended outcomes of the HII was not always clear, consistent or widely understood by multiple audiences. Concepts such as population health or systems change lack a shared meaning. This was a challenge among HII Grantees as well as those served by the Initiative. In many respects, these concepts were “ahead of the curve” of public opinion and understanding.
• Few audiences outside of public health understand, embrace or practice population health. The shift from a personal health care orientation to a population perspective among service providers and other sectors of the community has not occurred on a broad scale. More effort was needed to engage state and local elected officials. The HII was unable to invest additional time and resources in education and relationship building to address this challenge.
• Policy development, education and advocacy efforts were compromised by insufficient capacity and/or competing priorities. Many health partnerships were challenged to actively engage their communities in policy debate and policy change. Some health partnerships appeared to lack an understanding of the local opportunities (versus state level) to create a favorable policy environment. In contrast, HII Grantees that addressed statewide advocacy issues such as nonpartisan analysis, use of data, strategic alliances, media advocacy and publication strategies were far more successful than the local health partnerships Grantees. The skills set required to address policy may be quite different from the skills required to implement other aspects of the health partnership goals/objectives. As a consequence, technical support made available was not initially utilized, and “early” policy successes for the health partnerships may have been delayed or lost.
• The impact of specific policy education and advocacy efforts was difficult to establish. While statewide Initiative Grantees made important contributions, it was difficult to quantify the policy achievements and establish attribution particular to local health partnerships. Short of legal policies enacted through legislation, the HII was challenged to identify compelling intermediate indicators of accomplishment. Methodological limitations in the evaluation of policy change also affected our understanding of statewide contributions.
• A nonpartisan statewide prevention platform embraced by elected officials is noticeably absent. It was evident that an expanded view of health was not widely understood or championed at the policy level. In addition, there appeared to be little political will to attack the cynicism among those who question the value of prevention. The political environment, term limits of elected officials and the expertise of elected officials and their staffs represented obstacles to a nonpartisan, state-level commitment to prevention.
• A state-level policy center faces challenges as a neutral convenor providing nonpartisan analysis, while refraining from advancing specific proposals. Although HII Grantees were effective in each of the aforementioned roles, frequently the advocacy role needed to be passed on to other entities to maintain trust among stakeholders and comply with lobbying restrictions.