Building Partnerships for Health: Lessons Learned

© Minister of Public Works and Government Services Canada, 1998

Cat. H39-422/1998E
ISBN 0-662-26510-6

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Table of Contents

1. Introduction
2. Research Methods
3. Lessons Learned
4. Conclusion
Appendix 1
Appendix 2
Appendix 3
Appendix 4

1. Introduction

The 1996 report Nutrition for Health: An Agenda for Action,¹ was the product of an intense process of intersectoral collaboration involving government departments, non-governmental organizations and the private sector.The Prairie Region Health Promotion Research Centre was contracted by the Health Promotion and Programs Branch of Health Canada to examine this experience, so that lessons learned by participants might be shared with others.

The importance of intersectoral collaboration in promoting health is being increasingly emphasized,² and formed the central theme of the 4th International Conference on Health Promotion. ³ In response to this interest, this report is intended to help others who are attempting to build partnerships among government departments, and among the public, non-governmental organizations and private sectors in order to advance health. The study's lessons deal with the structures and processes that facilitate effective intersectoral collaboration.

A full case study, well beyond the resources available for this research, could explore the impact of the Agenda and clarify the effectiveness of both the process and the product of the intersectoral collaboration. Although there are indications that the Agenda is being used in a variety of ways, this study could not address the question of impact systematically. In Nova Scotia, development of the national Agenda corresponded to a provincial initiative to develop a plan for nutrition. This provincial initiative was taken into account, both as an additional case of intersectoral collaboration, and to illuminate one aspect of the national Agenda development process, namely consultation with significant constituencies.

The lessons learned from creating the Agenda and the Nova Scotia experience are consistent with recent literature on intersectoral collaboration^4. The significance of this study is that it affirms what many of us already know about working with others, and suggests that we often fail to put it into practice.

2. Research Methods

The methods used in this study are described briefly below and in greater detail in the appendices.

Like a case study, this investigation employed multiple data collection methods in order to attain sufficient contextual and descriptive information to create a framework for the lessons learned. The research progressed in several phases.

2.1 Phase 1:
Descriptive Chronology and Semi-Structured Interviews

The research team assembled background materials and files from the Nutrition Programs Unit in Health Canada on the work of the Joint Steering Committee (JSC), the 18-member group that was responsible for creating and releasing the Agenda. This provided an empirical account of the events, referred to as a descriptive chronology, that was used to provide a historical context for interviews, and to begin to identify the challenges or tensions inherent in the process of intersectoral collaboration. A summary of the process of development of the Agenda is found in Appendix 1.

The descriptive chronology tells its readers little about why an intersectoral approach was chosen, how it was facilitated or managed, why certain problems arose, how they were overcome, how participants felt about the process, and what they learned from it. These questions were addressed by a series of semi-structured interviews with 11 people involved with the JSC or regional consultations on the draft document (see Appendix 2 for the list of interview questions). Individual interviews permitted divergence in opinion and frank expression of differing perspectives on the process in question. Unavoidably, however, for some respondents considerable time had passed since the work of the JSC (between one and two years, depending on when and for how long interviewees had participated in the process). As a result, there were inevitably problems of recall and selectivity in hindsight. The interviews were analyzed by the research team, summarized in a synthesis document and returned to interviewees for additional comments. This iterative technique was used to increase the trustworthiness of the analysis which, along with the descriptiv chronology, served in the next step as the basis for identifing key "generative themes" and questions for the second phase of research.

2.2 Phase 2:
The Story/Dialogue Workshops

This phase consisted of two day-long meetings in which those involved increating or using the Agenda participated in story/dialogue workshops. ⁵ The story/dialogue method (see Appendix 3) was developed in 1994-95 by a team of health promotion researchers and practitioners, with the support of Health Canada and the sponsorship of the Prairie Region Health Promotion Research Centre.⁶ The method draws upon the work of theorists in education, social science and feminism, international developers and qualitative researchers.

The goal of the method is to create generalized knowledge about practice, through a structured dialogue around related experiences. In essence, the story/dialogue method begins with participants sharing specific experiences centred around a generative theme. A generative theme is one that induces animated discussion among workshop participants. It concerns specific tensions, ambiguities or problems within practice. For the Agenda workshops, seven themes on the topic of intersectoral collaboration (see Appendix 4) were developed based on the interviews and the descriptive chronology. Four participants at each workshop agreed to prepare and share stories linked to one of the themes. The ensuing structured dialogue probed the account for additional description, explanation, synthesis and lessons for future action. The lessons, or insights, are a group product, a distillation of the practiceor experience-based knowledge possessed by the participants.

The first story/dialogue workshop, held in Ottawa, was attended by 13 people, some of whom had been members of the JSC and others who were knowledgeable about intersectoral collaboration from other experiences. The second, in Halifax, was attended by 10 people, all of whom had been involved either in consultations on the draft of the national Agenda, or in activities related to the development of the provincial nutrition action plan.

As in any research, the methodology used in this study had a profound influence on the results. The reader should keep in mind that:

• The knowledge conveyed in this report represents the insights of those who participated in the interview and workshop processes. The research funding limited the number of participants. Others may have experienced the intersectoral collaborative process differently or contributed different insights.
• The story/dialogue method builds toward consensus on key lessons. Although differences of opinion and the complexity of the underlying phenomenon being studied are accommodated, some of the rich diversity of opinion is lost in the final array of insights.
• The method demands considerable honesty and risk-taking by participants who are asked to share their different experiences and divergent interpretations of the process. The method is dependent on their reconstruction and recounting of experience and on their candor.

3. Lessons Learned

The lessons described here reflect primarily what was said by participants in the workshops, and secondarily in the interviews. As described above, the story-dialogue method anchors the participants' discussion firmly in the specific case and the personal experience of the storyteller related to a particular theme or tension surrounding practice.

Two other cautions need to be stated with respect to the lessons derived from the methodology. As a result of the selection process by storytellers, not all themes were explored equally and hence not all gave rise to equally rich constellations of insights. Additional workshops with more participants and more stories would have enriched the discussion but were beyond the resources available for this research. A second implication is that once participants have moved to broad insights, there is no further reference to the original case or story. Hence the discussion that follows contains few references to the Agenda and its particular process of development, except where such reference will aid the reader in understanding how a particular issue or tension became the focus of the workshop discussions. Since this research is not evaluation of the Agenda process, the discussion avoids any reference to whether the Agenda illustrated lessons as a negative or positive case.

Lessons are organized into the broad categories created in the two workshops. A brief summary of the main insights appears in boxed format at the beginning of the discussion of each category.

3.1 Pre-Planning for Intersectoral Collaboration: Being Sure of the Purpose

3.1.1 The Impetus for Intersectoral Collaboration

In summary:
Impetus for intersectoral collaboration can come from several sources:

• External requirement (international commitment)
• Outside pressure (NGO)
• Commitment to the value of intersectoral collaboration
• Desire to learn from a new process
• Resource restraints

Collaboration among groups and sectors can arise for a number of reasons: recognition of mutual interdependence, need to share knowledge and resources, or a desire to increase one's effectiveness by engaging a wider-than-usual range of organizations. Partners often have different motivations for participating in a collaborative process. But with any partnership, one group or sector usually gets the process going. In the case of the Agenda, the sector was the nutritionist community, and the impetus was the 1992 International Conference on Nutrition. Countries signatory to that conference's Declaration, including Canada, committed themselves to develop national nutrition plans of action.

Intersectoral collaboration is only one option for development of such a plan. It would not be uncommon, for example, for a plan to be drafted by government officials alone or in collaboration with a small group of academics, and then vetted with key stakeholders. But the International Conference on Nutrition encouraged a collaborative approach with multiple sectors, and even identified some of those sectors. Some of the nongovernmental organizations (NGOs) that participated in the conference believed that a broadly based nutrition plan with engagement from agriculture, industry and social policy sectors was needed, and encouraged Health Canada to get such a process underway. According to some who became involved, federal spending restraints meant that no new government resources were likely to be committed to implementing a national nutrition plan. To ensure its implementation, the plan needed the buy-in and support of other public, private and NGO sectors engaged in nutrition-determining areas. Others describe the motivation differently. Health Canada, through its Health Promotion and Programs Branch, had recently completed a national policy on healthy eating that had entailed extensive field consultations. By virtue of its commitment to health promotion, the value of intersectoral collaboration in policy and program development was recognized and favoured as an approach for developing the Agenda.

3.1.2 Clarifying the Purpose for Intersectoral Collaboration

In summary:
To clarify the purpose for intersectoral collaboration, the following points need to be considered:

• It is important to first determine whether intersectoral collaboration is the best approach to the policy development task.
• Groups who participate in drafting an action plan may be more committed to following through.
• In the absence of significant (new) public resources, the opportunity to shape the content of policy or action plans may be a key benefit obtained by participating stakeholders.
• Different stakeholders often have different motivations for participating in an intersectoral collaborative process.

The purpose of the Agenda process of intersectoral collaboration would seem straightforward: to produce a national nutrition plan of action. But the question of purpose is more complex.

There are several reasons why groups become interested in intersectoral collaboration. Careful thought needs to be given to the specific purpose, or purposes, for any particular partnering process, since the effort is likely to be considerable. What, precisely, is the need that only such a process might satisfy? In the case of the Agenda, most participants believed that their shared goals of improved health and nutritional well-being for Canadians required actions by groups and sectors beyond government.

For one thing, if these sectors became involved in drafting the terms of their actions, they might be more likely to follow through. This raises the issue of resources, not only to support the process, but to follow through on the product. The purpose of the process and the resourcing and follow up are linked.

One line of reasoning suggests that if new public resources will be committed to the issue in question, it may be less important to engage in a long process of collaboration. Access to new resources may be enough of an incentive for key stakeholders to buy into policy or program ideas created in more traditional ways. But if there are no new public resources in the offing, more emphasis needs to be placed on partnering. The opportunity to shape the final policy or program may be a key benefit for certain stakeholders.

Workshop participants identified the clarification of these issues as an important step in defining the purpose of intersectoral collaboration: to clarify whether an intense and relatively costly collaboration process is required to achieve the common purpose.

They also signalled the importance of clarifying the value or aim of the product an intersectoral collaborative process might create. What is a nutrition action plan supposed to look like or achieve? Answers depend on who is defined as the principal audience for such a plan. Some saw the audience as decision-makers in other policy sectors (such as agriculture, industry and social policy) or at different levels (such as school boards or local health departments). Others saw the audience as nutritionists and the plan as increasing their ability to see their work more broadly, and to position themselves more effectively in public education, policy and advocacy work. These differences demonstrated the varied motivations stakeholders had for participating in an intersectoral collaborative process. For example, they could have wanted to influence policy at a more senior level; to have a presence in an international arena; to put nutrition issues on the agenda of other policy sectors; or to raise fundamental issues of social equity and environmental sustainability. These questions are not self-evident but must be clarified and negotiated among partners.

3.1.3 Clarifying the Authority of an Intersectoral Collaborative Group

In summary:
To clarify the authority in intersectoral collaboration:

• It is important to understand that leadership is not the same as authority.
• Determine early in the process
• the scope for autonomous intersectoral collaborative group decision-making;
• the authority the group has over the final product of its work.

Leadership at the beginning of the process is important, and is often vested in the group, organization or government department that first calls stakeholders together. But leadership is not the same as decision-making authority, and the two need not reside with the same organization. It is important that a collaborative group quickly reach agreement not only on the purpose of its existence and the scope of its work, but also on its actual decision-making powers. What is its mandate? For example, in the case of the national Agenda, what power will the collaborative group have to determine the content of the action plan in view of the need to have the plan signed off by federal officials before being sent on to the Food and Agriculture Organization (FAO)?

Questions like this recur in any collaborative process among governments and NGOs, and rest partly on the broader tension between representative democracy (investing certain citizens with political authority through elections) and participatory democracy (influencing the decisions elected officials make). There is no single way of resolving this tension, but making it an explicit topic for discussion early in the collaborative process is essential.

3.2 Building the Partnership: Paying Attention to Power

3.2.1 Choosing the Partners

In summary:
When choosing partners who will participate in the intersectorial collaboration process, there is a need to:

• Balance numbers between major sectors (government, NGO, private, academic).
• Collaboratively develop explicit criteria for choosing additional partners, based on the purpose of the intersectoral process. For example, consider partners:
• with resources to contribute toward the purposes of the intersectoral collaboration;
• versed in group process;
• with a constituency that has an important stake in the issue; and
• committed to active participation.

An intersectoral process requires determining which sectors or groups should participate. The more forethought given to the reason for engaging participation by other sectors, the easier it becomes to know which groups should be invited to join.

No single checklist of criteria for selecting partners will fit every situation where intersectoral collaboration is thought to be helpful. One important consideration, however, is creating a balance among broadly defined sectors (e.g., government, NGO, private, academic) so that no one sector comes to dominate the process by sheer numbers alone. There may inevitably be tensions over the balance between government departments and non-governmental organizations. Government representatives may see it as an ongoing struggle to have other groups take ownership. For NGO representatives, the process may continue to appear to be government controlled. Balance should be, and be seen to be, achieved at the table.

It is also important that as an intersectoral collaborative group begins to form, the initial members discuss and seek consensus on the criteria for selecting additional partners. For example, some may believe it important that grassroots community groups are represented. Others may question the value of local groups participating in an exercise designed to create policy at a more senior level, unless they have an interest in and some knowledge about such policies.

3.2.2 Partners' Accountabilities

In summary:
Partners' accountabilities include:

• creating a transparent process for involving their constituencies in intersectoral collaborative decision-making
• ensuring a mix of disciplines in the intersectoral group
• sending representatives with individual skills and capacities pertinent to the issue
• formalizing these accountabilities among all group participants

Determining who represents a particular sector is another important decision. It may be that several groups speak for the same constituency, or an organization may represent a particular aspect of a constituency's interests, but not necessarily in all respects. Some ways to discriminate among alternative groups include the extent of their public authority or influence over the issue; the size of their membership base; their political and public credibility; the transparency of their accountability back to their constituency; and their ability to mobilize knowledge or other resources needed to act on the problem.

The process of choosing group partners never ends completely. On the one hand, it is important that partners make an early commitment to stay involved over the full course of the process. On the other hand, it is sometimes necessary to invite new groups to keep the process fresh and to meet new resource needs.

It may also be important to consider the range of disciplines or perspectives brought by those who represent sectors. The predominance of a particular discipline (for example, in the case of the Agenda, nutritionists) can create some difficulties in language, particularly for NGO participants from other backgrounds. The analytical capacity of the partnership may be strengthened by the inclusion of views of various disciplines as well as a variety of sectors.

For many individuals, being part of a process of intersectoral collaboration is a new experience. Inclusion of people with more experience in the actual process, and not just with the issue, is an asset.

Where representation is most effective, it rests partly on the strength or personality of the individual, and not simply on the importance of the sector being represented. This underscores the importance of being clear on the purpose of intersectoral collaboration, in order to determine the specific resources and skills different sectors and their representatives need to bring to the table. It also emphasizes the need for participants to have the support and backing of a clearly defined constituency or organization. But there are two essential qualities that any representative to an intersectoral collaborative process must possess: a passion for the issue, and commitment to a process of joint decision-making and power-sharing.

Finally, intersectoral collaboration involves agreements between organizations or groups. This means that the intersectoral group needs to be clear that its members are not simply participating as individuals with particular expertise. They must also be seen as organizational or sectoral spokespersons-not only by other participants, but also by the constituents they represent. It can become particularly important to reach agreement on the organization role played by partner representatives when the process involves direct consultation with members of constituency groups.

3.2.3 Partners' Powers

In summary:
To ensure an effective decision-making process:

• Participating groups must engage actual decision-makers in the intersectoral collaborative process, or ensure that their representatives have access to mechanisms for securing decisions and commitments from their organizations. Intimately tied to the issue of which sector is represented and who actually sits at the table is the question of the power of representatives to act on behalf of their organizations.

Intimately tied to the issue of which sector is represented and who actually sits at the table is the question of the power of representatives to act on behalf of their organizations.

Representatives who lack power within their own organizations may find it difficult to gain quick agreement on financial or other resource commitments to the work of the collaborating group. If those with decision-making authority are not at the table, this may limit the intersectoral group's ability to make plans that are binding on specific partner organizations. It is rare for senior decision-makers to commit the time required in order for an intersectoral collaborative process to develop actions and commitments that reflect the interests of the divergent participating groups. To be successful, the process requires either their proxy involvement through people empowered to negotiate certain commitments, or efficient mechanisms within partner groups to secure decisions and commitments.

3.2.4 Partners' Vision-Making

In summary:
Partners' must share a common vision. For that:

• An intersectoral collaborative group needs to take time early in the process to clarify its vision. This makes it easier to be explicit about what it is they are committing to, and helps avoid future confusion or misunderstanding.

An intersectoral collaborative group needs a common vision and shared goals. Only then can explicit expectations for the role of each group be made clear. Divergent groups can reach common ground by engaging in a process of vision-making. Without sufficient time spent on this task, the result may be confusion over what participants are being asked to commit to-confusion over the purpose and product of the process. Confusion can filter down to constituent groups involved in consultation processes: groups at times hold different ideas of what the collaborative process intends to accomplish. Making clear distinctions between short-term products and long-term outcomes, and the expectations of groups participating in the process relative to both, can minimize misunderstanding or distrust between partners.

3.3 Securing Partners' Involvement: Creating Ownership of the Product through the Process

3.3.1 Facilitating Group Process

In summary:
Facilitating an intersectoral collaborative group requires:

• a strong formal chair
• good record-keeping, especially of group agreements
• effective group facilitation
• commitment by all partners to the time required to develop group trust
• agreement by all partners on group process norms
• agreement by all partners to be open about their agendas
• commitment by all partners to the time required to discuss and analyze differences between partners' interests in, and understandings of the issues
• flexibility in moving between large groups "of the whole" and smaller task groups
• commitment to ongoing evaluation of group dynamics and group accomplishments

Although intersectoral collaboration involves agreements among organizations, these agreements are mediated through individuals. The actual process takes on characteristics common to most small groups, where there is a constant tension between group process and task accomplishment. The process will benefit from skilled management of these functions, and the role of the chairperson can be critical. It involves managing agreements between organizations and requires someone to whom the rest of the group grants a degree of formal authority. Part of this function includes formal record-keeping of group agreements and decisions.

In addition to this chairing and recording function, the process requires group facilitation. Here, attention is paid to nurturing relations among individuals, providing encouragement, celebrating successes and creating safety in the process and trust in its integrity. Building trust requires that the group process itself-i.e., the norms of group behaviour, decision-making and meeting processes-becomes a topic of group discussion and agreement. It also requires that all partners agree on the value of trust-building and good group process, the by-products of intersectoral collaborative work.

Managing the group process may require a skilled neutral facilitator or coordinator, someone other than the chairperson. There would be advantages to the facilitator's not being directly employed in one of the partner groups: an employee might have or be seen to have a vested interest; an employee may feel constrained about intervening around issues of power if in a direct line relationship with other people at the table. An independent facilitator is in a better position to resolve the conflicts that almost inevitably accompany a collaborative process.

Ground rules for group processes should be made explicit and agreed upon early in an intersectoral collaborative undertaking. Rules should include a requirement that all partners make their own interests or agendas explicit. Partners are likely to have diverging assumptions or analyses about why problems exist and how they can be solved. Being open and explicit demands considerable trust among partners, particularly when they may be competing for scarce resources. These differences should be properly aired and respectfully debated. Otherwise, they can cause repeated collisions rather than recognition of commonalities. The end result may be a consensus more apparent than real.

Group process is related to group size, and intersectoral collaborative work is not immune to the challenge of sheer numbers. Too large a group detracts from good problem-posing and joint decision-making. But too small a group excludes sectors that might make an important contribution. The structure of an intersectoral collaborative group should be flexible so that larger groups "of the whole " engaged in creating a common vision, defining goals and negotiating resources can subdivide into smaller groups when focused tasks are required.

Finally, as with any undertaking, it is helpful to formalize and incorporate an evaluation process of the ongoing work.

3.3.2 Creating Ownership

In summary:
Creating ownership in an intersectoral collaborative process and product may be enhanced when:

• Partners are required to "pay in," with financial or in-kind resources.
• Richer partners subsidize the pay-in of less well-resourced partners.
• Decisions and final products reflect the particular language and issues of each partner.
• Partners are obliged to consult formally with their constituencies.
• The approval and ownership requirements for different partners are identified and respected.
• The partners reach clear decisions on the trade-offs between products that achieve a broad sense of ownership, and defining specific policy interventions as the responsibility of certain groups or sectors.

Partners must feel a sense of ownership of decisions reached if they are to commit their own resources to follow up. Buy-in by all partners to the process and its products is often an explicit goal of intersectoral collaboration. Human, physical and financial resources are needed to facilitate partnership development and may be contributed disproportionately by one partner. But when no single partner has the capacity or is prepared to fully back the process and its follow up, all partners must be prepared to contribute. "Paying in" to the collaborative process, whether in cash or in kind, is one means of creating buy-in. Partners who contribute materially to a process and its products may develop a stronger stake in following through on the work.

The issue of sharing resource responsibility for intersectoral collaborative work is a complex one. First, there may be considerable unevenness in the resource base brought to the table by different partners. For partners to develop trust in the integrity of the process, there must be willingness for "richer" stakeholders to help "poorer" ones financially in their participation. Second, what looks like a good collaborative process to one partner may appear to another to be unloading responsibility.

Second, commitment of finances is no guarantee of buy-in. Richer partners can commit more resources yet still feel little obligation to the final product. Partners with little to contribute beyond the time and expertise of their representatives may bring considerable passion to the process and become major supporters of the final product.

Ownership can mean different things to different partners. For government departments, securing sign-off by ministers can be an important stamp of ownership. But this may mean little to NGOs. These differences, like others discussed above, need to be discussed to ensure that the real and symbolic indicators of ownership are mutually understood and accommodated.

Ownership is enhanced when partners see their own language and ideas reflected in the work of the group. Consultations with their own constituencies allow partners to position the intersectoral collaborative project, and its issues, in terms that will engage their own members, as well as interest potential partners not directly involved in the process but with a stake in the decisions.

Finally, much of the rhetoric around intersectoral collaboration is about creating plans or policies that "everybody owns." Considering all the challenges to this achievement-differences in agendas and group interests; differences in language and assumptions related to analysis of issues; differences in resources and processes of generating commitment to a final product-it is likely that in any instance of intersectoral collaboration there will be divergent views about its overall success. Although lacking in specific recommendations, a final product in the form of a plan that is broad in scope may be useful to a wide array of constituents, ranging from small, grassroots organizations to those lobbying for policy changes in diverse settings. On the one hand such a broadly stated plan may not compel action on the part of any actor; on the other hand it may signal that action is the responsibility of many sectors and groups. In the end, creating ownership is a major challenge in intersectoral collaboration. It may require a trade-off: by not assigning responsibility for action, it may provide legitimacy for many groups to act.

3.4 Following Through on the Action

3.4.1 Clarifying the Basis for Action

In summary:
Follow up on intersectoral collaboration requires:

• formalized agreements among partners
• information sharing on follow up
• a focal point responsible for monitoring follow up
• early clarification of the expected benefits of intersectoral collaboration relative to its costs, with ongoing evaluation of whether the costs are warranted

Establishing a basis for follow up action is related to issues discussed earlier, including clarifying the purpose of the intersectoral collaboration and explaining its mandate. Sometimes groups will start with broad issues and general strategies, and use consultations with constituencies to garner support as well as input, making it easier for decision-makers to buy into the final product. This might be described as a cautious, non-confrontational approach. It can foster a slow but sustainable process of building acceptance for the final product.

Developing plans for securing partners' ownership and involvement in follow up is essential. This would ensure that follow up actually occurs beyond the period when partners meet as an intersectoral collaborative group. If partners are to follow through on their decisions, they must make explicit agreements to do so. This underscores the importance of establishing early a common understanding of the goals and objectives, the scope of the issues, and differences in interpreting the issues.

What would a formalized agreement about follow up entail? It should constitute a framework for time commitment, action and accountability; commitment to share information on how each partner is implementing its actions; a mechanism for collecting and distributing information on follow-up actions; and a single focal point responsible for monitoring follow up.

If partners are unfamiliar with intersectoral collaboration, or are meeting for the first time, there is a period of confusion when considerable energy needs to be devoted to group facilitation, trust-building, and airing differing agendas. Formalizing agreements on follow up too early in this process can bind a group to a task that might not be the most productive use of resources. This is particularly true when partners themselves are in a state of organizational transition, and may be unable to make the kind of binding commitments demanded in formal agreements. But the absence of formalized agreements at some point in the process ultimately weakens the final product by failing to secure partners' commitments to follow-up action. It also raises the question of whether such a process warrants the resources expended.

3.4.2 The Role of a Champion

In summary:
Follow up action, in addition to requiring formalized agreements, also needs:

• passionate and committed champions.

Even the best intersectoral agreements can languish if there are no strong internal champions who will hold their organizations accountable. The importance of having a passionate commitment to the issues cannot be overemphasized. Although the process is described in terms of organizations developing common understandings, sharing resources, and making collective agreements, it is obviously individuals who make these decisions. Their enthusiasm and interest in the underlying issues are critical factors in the success and impact of the endeavour.

3.5 Consulting Constituencies

In summary:
Consultations can enhance the intersectoral collaborative process, provided that:

• Sponsors are clear on the precise need for, and goals of, consultation
• The consultations are backed by people with decision-making authority.
• They are customized for the interests and needs of particular groups or constituencies.
• There is sufficient time for groups to read and prepare comments on the materials around which the consultation is focused.
• The final product incorporates the ideas and actual language of the groups consulted.

A clear purpose is essential for any consultation. As with other aspects of the intersectoral collaborative process, clarifying purpose is sometimes not accorded the time and energy it deserves. It is quite possible for groups being consulted to misunderstand their role in the process. This confusion can lead to considerable non-response by key groups whose ideas, comments and sense of ownership of the final product are important. Engagement in a consultation process is also determined, in part, by the perceived authority of the organizers. That is, participants need to perceive that the larger intersectoral collaborative process involves people with actual decision-making power, so that their input can be acted upon.

While some standardization of a consultation process is helpful-for example, using background materials, a facilitator's guide and a collective response form-there is still a need to tailor each consultation to the interests and style of the consulted group. Moreover, sufficient time must be given to read the background documents and to prepare comments. This is particularly true for voluntary groups, who are frequently asked to consult on a range of policy initiatives with little forewarning or financial support. Successful consultation also requires a reflective modesty on the part of the group calling for the consultation; the issues that have assumed burning importance to them may not be as important or immediate to other groups or organizations.

Too often consultations become token events in which the claim to have consulted is more important than the ideas generated by the process. This leads to cynicism in public policy and unfairly exhausts the resources of volunteers. Participants can expect that their input will influence the final product. If fulfilled, these expectations contribute significantly to the development of a sense of multisector ownership of the process and product.

Resourcing the consultation process can be shared among partners. Different sectors cooperate with different consultation meetings, and some can put in tangible resources for the consultations. Member organizations who are partners in the intersectoral process can take on responsibility for organizing consultations within their particular sectors.

4. Conclusion

Despite the increasing recognition of intersectoral partnerships in creating healthy public policy as an important strategy for promoting population health, the process for developing these partnerships is not well understood. It is important to reflect on case examples, such as the intersectoral collaboration that produced Nutrition for Health: An Agenda for Action. The lessons generated should prove helpful for other groups or organizations wishing to initiate an intersectoral collaborative process.

Summary of Main Insights

As a quick reminder, the brief summaries of the main insights are repeated below. Impetus for intersectoral collaboration can come from several sources:

• external requirement (international commitment)
• outside pressure (NGO)
• commitment to the value of intersectoral collaboration
• desire to learn from a new process
• resource restraints

To clarify the purpose for intersectoral collaboration, the following points need to be considered:

• It is important to first determine whether intersectoral collaboration is the best approach to the policy development task.
• Groups who participate in drafting an action plan may be more committed to following through.
• In the absence of significant (new) public resources, the opportunity to shape the content of policy or action plans may be a key benefit obtained by participating stakeholders.
• Different stakeholders often have different motivations for participating in an intersectoral collaborative process.

To clarify the authority in intersectoral collaboration:

• It is important to understand that leadership is not the same as authority.
• Determine early in the proces
• the scope for autonomous intersectoral collaborative group decision-making;
• the authority the group has over the final product of its work.

When choosing partners who will participate in the intersectorial collaboration process, there is a need to:

• Balance numbers between major sectors (government, NGO, private, academic).
• Collaboratively develop explicit criteria for choosing additional partners, based on the purpose of the intersectoral process. For example, consider partners:
• with resources to contribute toward the purposes of the intersectoral collaboration;
• versed in group process;
• with a constituency that has an important stake in the issue; and
• committed to active participation.

Partners' accountabilities include:

• creating a transparent process for involving their constituencies in intersectoral collaborative decision-making
• ensuring a mix of disciplines in the intersectoral group
• sending representatives with individual skills and capacities pertinent to the issue
• formalizing these accountabilities among all group participants To ensure an effective decision-making process:
• Participating groups must engage actual decision-makers in the intersectoral collaborative process, or ensure that their representatives have access to mechanisms for securing decisions and commitments from their organizations.

Partners' must share a common vision. For that:

• An intersectoral collaborative group needs to take time early in the process to clarify its vision. This makes it easier to be explicit about what it is they are committing to, and helps avoid future confusion or misunderstanding.

Facilitating an intersectoral collaborative group requires:

• a strong formal chair
• good record-keeping, especially of group agreements
• effective group facilitation
• commitment by all partners to the time required to develop group trust
• agreement by all partners on group process norms
• agreement by all partners to be open about their agendas
• commitment by all partners to the time required to discuss and analyze differences between partners' interests in, and understandings of the issues
• flexibility in moving between large groups "of the whole" and smaller task groups
• commitment to ongoing evaluation of group dynamics and group accomplishments

Creating ownership in an intersectoral collaborative process and product may be enhanced when:

• Partners are required to "pay in," with financial or in-kind resources.
• Richer partners subsidize the pay-in of less well-resourced partners.
• Decisions and final products reflect the particular language and issues of each partner.
• Partners are obliged to consult formally with their constituencies.
• The approval and ownership requirements for different partners are identified and respected.
• The partners reach clear decisions on the trade-offs between products that achieve a broad sense of ownership, and defining specific policy interventions as the responsibility of certain groups or sectors.

Follow up on intersectoral collaboration requires:

• formalized agreements among partners
• information sharing on follow up
• a focal point responsible for monitoring follow up
• early clarification of the expected benefits of intersectoral collaboration relative to its costs, with ongoing evaluation of whether the costs are warranted

Follow up action, in addition to requiring formalized agreements, also needs:

• passionate and committed champions.

Consultations can enhance the intersectoral collaborative process, provided that:

• Sponsors are clear on the precise need for, and goals of, consultation.
• The consultations are backed by people with decision-making authority.
• They are customized for the interests and needs of particular groups or constituencies.
• There is sufficient time for groups to read and prepare comments on the materials around which the consultation is focused.
• The final product incorporates the ideas and actual language of the groups consulted.

Appendix 1

Précis of the Descriptive Chronology

The following summarizes the process of development of Nutrition for Health: An Agenda for Action.

December 1992
International Conference on Nutrition, Canada's commitment to develop a national plan of action for nutrition.

National Institute of Nutrition asked Minister of Health to follow up on the commitment.

Summer 1993
Preliminary meeting to discuss how to organize a process for developing the response.

September 1993
First meeting of the Joint Steering Committee (JSC) decided on additional members and background work that included:

• updated Country Paper Canada
• environmental scan
• survey of activities on implementation of recommendations of Action Towards Healthy Eating
• four think-tanks
• review of food quality and safety programs
• review of programs for preventing nutrition-related diseases and monitoring nutrition status.

September 1993 - Spring 1994
Requests for proposals, hiring of contractors, conducting work, deciding on participants, reviewing drafts of reports on the above; reports completed.

Activity Survey Task Group and Consultation Task Group formed.

Communications ongoing with provincial/territorial government representatives and constituencies of JSC members.

April 1994
Selection process for hiring contractor to write the national action plan.

Summer 1994
JSC reviewed two drafts of document. September 1994
JSC not satisfied with paper and decided not to proceed with the consultation process.

October 1994
A small drafting group was formed to work on the document.

December 1994
The drafting group met; work resumed on development of the Consultation Kit for consultations on the draft document.

January - May 1995
The drafting group wrote document.

April 1995
Draft reviewed by selected individuals.

May - October 1995
Consultation process organized by many groups to review the draft action plan; number of evaluation reports submitted by groups from different sectors.

December 1995
JSC meeting to review feedback on draft and to review the report on indicators.

March 1996
Final version of Nutrition for Health: An Agenda for Action approved by JSC.

May 1996
Document jointly endorsed and released by Minister of Health and Minister of Agriculture and Agri-Foods.

Agenda Report delivered by Minister of Health to the Food and Agriculture Organization and the World Health Organization at the World Health Assembly.

Document distributed to provincial and territorial ministers of health, to contacts developed in the process, and to constituencies of the many players.

1996 - 1997
Nutrition Programs Unit (Health Canada) took initial steps toward development of a system for the ongoing collection, analysis and reporting of indicator data.

1994 - 1997
Development of the Nova Scotia Agenda.

1995 - 1997
Development of Canadian Dietetic Association (Ontario) project on advocacy skills for dietitians.

Appendix 2

Interview Guide

I Interviewee information:

I'd like to begin by asking a few questions about your role in creating the Agenda.

How long were you involved in the project?
How would you describe the extent of your involvement? (e.g. very, somewhat).
In the larger context of your work at the time, how important to you was your involvement? Why?
How important was it to the organization or agency where you worked? Why?

II Agenda background information:

Now I'd like to ask a few questions about the Agenda document itself.
Why was a national action statement considered the best response to the issue of nutrition?
Was there any debate about this as an outcome?
Comments on the first draft posed the question: "Is it a plan or a policy framework?" How would you respond?
Preparing the Agenda was an intersectoral process. What sector would you say you represented?
How were other sectors or stakeholder groups chosen? Why?
Were there any stakeholder groups that should have been there, but were not? Why?

III Agenda process information:

How would you describe the process used for developing the Agenda?
Who chose this process? Why do you think it was chosen?
What positive impacts do you think the process had on the final content and format of the Agenda? Why?
Were there any negative impacts of the process on the content and format? Why?
What characteristics of the process would you say were most important in allowing participants to complete the task? (Select the one or two most important ones.) Why?
What characteristics of the process would you say were least effective?
(Select the one or two most important ones.) Why?

IV Follow up to the Agenda:

What role have you taken in promoting or using the Agenda since its release? Why?
How would you describe the impacts of this use?
From your vantage point, and to the extent that you've kept up with developments on the Agenda, how has it been used since its release?
Is there anything else you'd like to add that would help us in analyzing the process of intersectoral development of the Agenda?
Is there anything else you'd like to add that would help us to analyze the Agenda's impact on actions?
Are there any questions you have for the case study team?

Appendix 3

The Story/Dialogue Workshops

The story/dialogue method was developed in 1994-95 by a team of health promotion researchers and practitioners, with the support of Health canada and the sponsorship of the Prairie Region Health Promotion Research Centre ⁷. The method draws upon the work of theorists in education, social science and feminism, international developers and qualitative researchers.

Key Elements in the Story/Dialogue Method

Generative Themes

A enerative theme is one that induces animated discussion among workshop participants. It concerns specific tensions, ambiguities or problems within practice. For the Agenda workshops, seven themes on the topic of intersectoral collaboration (see Appendix 4) were developed based on the interviews and the descriptive chronology. The first four were the focus of the Ottawa workshop, and the last three were the focus of the Halifax workshop. Each theme contains a brief description and a number of questions around which several participants were asked to prepare "case stories" in advance of the workshop.

Case Stories

Four participants at each workshop agreed to be storytellers. Storytellers prepared case stories on one of the generative themes for the workshop (e.g., when I encountered this practice problem, I did this...because...and this happened...). All storytellers received printed information on how to prepare a case story.

Story Groups and Structured Dialogue

Too often practitioner discussions leap from description to action without enough time devoted to explanation. The structured dialogue is an attempt to move discussion logically around four broad categories of question: What? Description), Why? (Explanation), So What? (Synthesis) and Now What? (Action). During a workshop, case stories are shared and analyzed in story groups.For this study, each workshop had two story groups with between six and nine people in each group. Two people in each group were storytellers.

Each round of storytelling and structured dialogue begins with one storyteller sharing a case story. This is followed by a reflection circle in which other story-group members speak briefly about how the story touches their own experience. This is followed by a structured dialogue on the case story with time allotted to discussion that focuses on the "why?", "so what?", and "now what?" noted above. The other story-group members take turns as story-recorders, making notes on key points during this structured dialogue. The credibility of the findings generated by a story group increases with the number of stories shared and analyzed. Each story group went through two rounds of storytelling and structured dialogue during the workshops.

Insight Cards

Using the notes kept by story-recorders, the story group distills key lessons offered from the dialogue around each story into a number of insight cards. These statements represent "ah hahs!" about the generative theme that storygroup members believe are important enough to share with others. In the Agenda workshops, after two rounds of storytelling and structured dialogue, each story group generated between 20 and 30 such insight cards.

Categories and Theory Notes

Insight cards are organized into categories. This step resembles the stage of inductive analysis used in qualitative research. The contents of each category are then re-written into individual theory notes (e.g., "How would you describe the ideas on the cards in this category to someone else?"), and the notes for each category organized into their own logical sequence. Theory notes retell the stories analyzed by the story group but use more generalized language. In theAgenda workshops, instead of theory notes, each story group organized their insight cards into categories and their categories into a logical order. They presented their insights to the other story group, whose members were invited to ask questions to clarify the theory presented by the cards and the categories. Clarifying notes were added as needed.

Reflections on the Story/Dialogue Workshops

Each workshop ended with participants reflecting briefly on the day's work. In both workshops, several participants expressed a sense of closure that the workshops afforded. Some storytellers found it almost cathartic to share their experiences in the story groups. Many found that the story-dialogue method helped to illuminate aspects of their work on the Agenda that they had not recognized previously. Several were surprised at the range and quality of insights they had generated in a short time, although a few thought that the insights cards lacked depth. Others commented on:

• the value of the method in encouraging reflection;
• how such a process would have been helpful in earlier stages of their intersectoral work;
• the value of the four categories of question in the structured dialogue, which helped lead participants into a frame of thinking that was itically self-reflective;
• the rapidity with which trust among story-group participants eveloped, in contrast to the slowness with which trust developed in actual collaborations around the Agenda; and
• how the method could be used in other areas of their current work.

While the workshops tended to highlight problems in the processes of collaboration and consultation used in creating the Agenda, many participants left with renewed excitement over the importance and value of intersectoral collaboration generally, and the usefulness of the Agenda in particular.

Appendix 4

Generative Themes for Story/Dialogue Workshops

1. Who's at the Table: Choosing Sector Representation

Intersectoral work requires representation of sectors that can make significant contributions to issue analysis, decision making and action.At the same time, too large a committee creates problems in group dynamics. What criteria might guide selection of sectors to be represented? How can thorough sector representation be balanced with good group process?

Intersectoral collaboration often requires a balance between a lead convening) partner that provides resources and logistical support, and other partners expected to buy in by "paying in." How can domination by any one sector, whether actual or perceived, be avoided? What special challenges arise when the lead partner is government, and the intersectoral process involves collaboration among different branches of government as well as among government and non-governmental organizations? What criteria might be used when choosing organizations to represent a sector? In a collaborative venture, individuals are chosen to represent participating organizations. Decision-makers, or people with good access to ecisionmakers, are needed as members of the collaborative committee, but these people may find it difficult to accommodate the time commitment required. How can this level of representation be achieved? How should representatives be accountable to their constituencies, while also being accountable to the collaborative process/committee? Individuals differ in their ability to act comfortably and confidently on committees, and may feel or be perceived as more or less powerful than others on the committee. What personal attributes should be considered when choosing an individual to represent a sector?

2. The Table Changes: Maintaining Membership in an Evolving Environment

Intersectoral collaboration requires interpersonal as well as interorganizational partnership development. Continuity in membership eases group process and group decision making. Over longer collaborative endeavours, such as the JSC, membership can change. This is especially so in the present fiscal climate where organizations are losing resources and continually reorganizing. What problems does this create for good collaboration? What steps can be taken to minimize these problems? What are some ways to invigorate a lengthy process of committee work without compromising integrity or momentum? Can the whole process be carried out more expeditiously and be equally effective?

3. Collaboration at the Table: Creating Buy-In

At the core of intersectoral collaboration lies the challenge of learing to deal constructively with power differences, between organizations (sectors) and individuals (representatives). How are agreements achieved on sharing power and authority? Intersectoral collaboration requires buy-in from all partners. What does buy-in actually mean? What are the pros and cons of representatives returning to their organizations for confirmation or agreement on decisions made at the collaborative table? Partners may take on specific tasks requiring them to make financial/human resource commitments. But there can be suspicion that the lead partner may be using the process because it does not have sufficient resources to do the work itself. Partners may feel themselves being "used." If it provides more of the resources, the lead partner may be seen as exercising control over the process. How can the group ensure that power isnot associated with only cash or in-kind input? How is responsibility for creating buy-in shared by all partners in the collaborative process?

4. Owning the Product: Achieving Consensus

Achieving consensus among collaborating groups is often difficult; group process becomes important. One or more committee members of a artner organization may be assigned key roles in facilitating this consensus-building process. What characteristics of this facilitation are most helpful in achieving consensus?

Specifically, how is agreement reached on what the collaborative process is intended to achieve? How are the differing motivations for collaboration, and differing interests of the sectors, dealt with at the level of collaborative decision-making? What are other characteristics of the process that help produce a consensus? How does the process, and the time and effort it demands, strengthen or weaken the final product?

5. Maximizing the Benefits of Consultation

Intersectoral policy development requires consultation beyond the people who meet in collaborative committees. This consultation helps to increase buy-in by more members of the constituencies represented by the partner organizations. It brings in a broader range of knowledge and ideas. At the same time, consultation may be perceived as tokenistic or superficial, and it can also be costly in human and financial resource commitment. What are criteria for successful consultations? How can a collaborative committee determine the best use of such consultations, relative to their costs? How can a consultation process avoid being tokenistic?

6. Determining the Usefulness of the Final Product

The structure and format of a policy outcome of an intersectoral collaborative process (e.g., the Agenda) can be a factor in how it is subsequently used. How important is it to take structure and format into account when designing a policy outcome? Should the policy outcome be expressed in inclusive and generalized terms so that everyone can make connections with it in some part of their work, or should it be focused and targeted to certain decision-makers? Should the product be identified with any particular organization such as a government department? How is this a strength or a weakness of a policy outcome? Who really owns the policy outcome? How does the tone, format and content of the product make it useful for education, advocacy or motivation?

7. Following Up with Action Plans

When the product of intersectoral work takes the form of a statement or a policy, it requires champions from within the different sectors to promote it. How does the intersectoral process of creating the product (e.g., the Agenda) help to create or support such champions? How do the final product, and the consultations involved, stimulate action within and among sectors involved in the collaboration or the consultation process? How important is research and consultation in making the product useful? Compare that process with having a similar product prepared by a small working group, over a limited period of time, with no consultation.

With regard to the Agenda in particular, what specific actions have arisen in which the Agenda played a key role? What specific characteristics of the Agenda enabled it to play this role?

Footnotes

¹ Joint Steering Committee responsible for development of a national nutrition plan for Canada. Nutrition for Health: An Agenda for Action. Ottawa,1996.

² Federal, Provincial and Territorial Advisory Committee on Population Health. Strategies for Population Health: Investing in the Health of Canadians. Ottawa: Minister of Supply and Services Canada, 1994. Canadian Public Health Association. Action Statement for Health Promotion in Canada. Ottawa: CPHA, 1996.

³ World Health Organization. The Jakarta Declaration on Health Promotion into the 21st Century. Geneva: World Health Organization, 1997.

⁴Costongs, C. and J. Springett. "Joint working and the production of a City Health Plan: the Liverpool experience," Health Promotion International 12(1):9-20, 1997.
Fieldgrass, J. Partnerships in Health Promotion, London: Health Education Authority, 1992.
Canadian Public Health Association. The Canadian Experience of Intersectoral Collaboration for Health Gains, Ottawa: Canadian Public Health Association, 1997.
Labonte, R. Power, Participation and Partnerships for Health Promotion, Melbourne, AU: VicHealth Foundation, 1997.

⁵Labonte, R. and J. Feather. Handbook on Using Stories in Health Promotion Practice, Ottawa: Minister of Supply and Services Canada, 1996.

⁶ Feather, J. and R. Labonte. Sharing Knowledge Gained From Health Promotion Practice, Saskatoon: Prairie Region Health Promotion Research Centre, University of Saskatchewan, 1995.

⁷ Feather, J. and Labonte, R. Sharing Knowledge Gained From Health Promotion Practice. Saskatoon: Prairie Region Health Promotion Research Centre, University of Saskatchewan, 1995.