Indonesian Society for Urban Health (ISUH): Partnership and Health Promotion

1. Introduction

Working in partnership has been recognized internationally as an effective way to address a variety of health problems including the implementation of healthy cities policies. Many studies have shown that involving diverse sectors from different departments; organizations and background will be much more effective than organizations operating independently. However, partnership in health promotion is not easy to be implemented. Therefore, first section explains the basic concept of partnership including the meaning of partnership, different types of partnership and the importance and benefit gained by organizations by partnering. Second section explains the theories and models of an effective partnership.

2. Basic Concept of Partnership

2.1 The meaning of partnership

This section aims to understand the meaning of partnership. This is important because the word ‘partnership’ is one of the words which has several and ambiguous meaning. Lowndes (2001) comments that a partnership may be a means of getting people to begin a debate or share information, a contractually arrangement for service delivery, or it may even be a policy-making forum (Hamdi & Majale, 2005 p.27). Poole (1995:2) explains partnership as ‘an association between two or more persons, groups, organizations who join together to achieve a common goal that neither one alone can accomplish. This association is characterized by joint membership rights, democratic participation and shared responsibility. Each member agrees to contribute resources to the partnership with the understanding that the possession or enjoyment of the benefits will be share by all. Partners work hard to strengthen each other and to endure conflict and change, because they recognize that their shared goal extends beyond the reach of any one member’ (Hamdi & Majale, 2005 p.27).

Demirjian (2002:5) argues that partnership as ‘a agreed-upon arrangement between two or more parties to work collaborative toward shared objectives-an arrangement in which there is (a) sharing of work, responsibility and accountability; (b) joint investment of resources; (c) shared risk-talking; and (d) mutual benefits’ (Hamdi & Majale, 2005 p.27). Partnership for health promotion focuses on health outcomes rather than specific health promotion goals. Gillies (1998) explains that partnership for health promotion is a voluntary agreement between two or more partners to work cooperatively toward a set of shared health outcomes (Gillies, 1998). Partnership is a voluntary collaborative agreement between two or more parties in which all participants agree to work together to achieve a common purpose to undertake specific tasks, and to share risks, responsibilities, resources, competencies and benefits (Tagunicar, 2009). Roussos and Fawcett (2000) explain that partnership is an alliance among people and organisations from multiple sectors, such as schools and businesses and other stakeholder, working together to achieve a common purpose (Roussos & Fawcett, 2000). The Audit Commission (1998) points out that partnership as ‘a joint working arrangement where partners are otherwise independent, agree to cooperate to achieve a common goal, established new organizational structure or process to achieve this goal, plan and implement a joint program, and share relevant information, risks and rewards’ (Baggott, 2007 p.156)

Based on those definitions as mentioned above, scholars have different view point in explaining and defining partnership. However, there is a consensus suggesting that partnership relates to eight key ingredients:

· Partnership is a voluntary agreement (Gillies, 1998; Tagunicar, 2009).

· Partnership involves various organizations, groups, agencies, individuals and disciplines (Baggott, 2007; Gillies, 1998; Roussos & Fawcett, 2000; Tagunicar, 2009)

· Partnership has general purposes and goals among partners (Baggott, 2007; Gillies, 1998; Hamdi & Majale, 2005; Roussos & Fawcett, 2000; Tagunicar, 2009).

· Partnership requires shared risks, benefits, rewards and outcome (Baggott, 2007; Gillies, 1998; Hamdi & Majale, 2005; Tagunicar, 2009)

· Partnership requires shared resources both monetary and non-monetary (Baggott, 2007; Gillies, 1998; Hamdi & Majale, 2005; Tagunicar, 2009).

· Partnership requires shared power, authority; responsibility and accountability (Gillies, 1998; Hamdi & Majale, 2005; Tagunicar, 2009; Wildridge, Childs, Cawthra, & Madge, 2004).

· Partnership recognizes partners autonomy and independency (Baggott, 2007)

· Partnership creates a new organizational structure (Baggott, 2007).

To determine what there is or not a partnership in which you or I involved a program or project, Frank and Smith (2000:6) emphasize that in general a real partnership does not exist when ‘there is a simply gathering of people who want to do things; there is a hidden motivation; there is an appearance of common ground but actually many agendas exist; there is tokenism, or the partnership was established just for appearances; one person drives all the process or has all the authorities; and there is no sharing of risk, responsibility, accountability and benefits’ (Hamdi & Majale, 2005 p.28)

2.2 Different forms of partnership

Definitions of partnerships vary. This section explains different types of partnership. Partnership can be categorized into several groups: nature of outcomes, topics and institution, level of government and inside or outside community. Partnership by nature of outcomes can be divided into four dimensions: strategic, technical, financial, and implementation (WHO, 2004). Strategic partnership aims to influence the strategic plan of other departments, to influence other departments than just department of health, and to influence general population. Technical partnership focuses on how partnerships strengthen technical cooperation from top to down level. Financial partnership means partners provide funding for implementing programs while the implementation partnership is partners provide technical and policy in-country or cities work.

Partnership also can be divided by topics such as health, society, and economy and institutions such as public and private sector and NGOs. Further, partnership can be seen from the level of government such as national, regional, local and community level (Hamdi & Majale, 2005). Hamdi and Majale (2005) divided three form of operational partnership: associative partnership, partnership entities, and partnership networks. Associative partnership is in which involvement is negotiated in pursuit of certain objectives. Partnership will break up when the specific objectives have already been met. Partnership entities arise in which an institution is created with some sense of official decision making structures. Then, partnership networks is in which institutions get control to influence decisions, rights, and access (Hamdi & Majale, 2005).

Building partnership can be also divided according to position from the community: within or outside community. Partners from inside community include slum and religious leaders, and community groups while outside community include polices, politicians, governmental agencies, and donor agencies (Booth, Martin, & Lankester, 2001). Rodal and Mulder (1993) as cited in TBS (1998) categories partnerships according to key point and level of sharing: consultative, contributory, operational and collaborative partnership (Hamdi & Majale, 2005). Powell and Glendinning (2002) classify partnership according to which sectors are involved: public-private sector; public-public sector; public-voluntary sector; and public-community sector (Boydell, 2007; Glendinning, Powell, & Rummery, 2002) Partnership involves these sectors as multi-sectoral partnership. However, it is hard for certain partners to involve them to certain program. It may be easier for government, for example, to involve them in partnership for achieving public goods interests but hard for private sector (Skelcher, 2003). Likewise, it is easier for community organizations to reach vulnerable or disadvantage groups than public and private organizations.

There are different types of working together between institutions which can be represented along a continuum. Figure 1 describes the Continuum of Joint Effort developed by Success Works (2002). The Continuum of Joint Effort provides and explains the level of partnership based on the desired outcomes. There are two main components of the Continuum of Joint Effort according to the picture: participatory consultation in horizontal side and level of intensity and commitment in vertical side. The higher the degree of intensity and commitment, the lower participatory consultation partners have, conversely the lower the degree of intensity and commitment, the higher the participatory consultation they need. Therefore, networking, cooperation, coordination, collaboration and partnership are one line that explains the desired outcome between participatory consultation and the level of intensity and commitment. The key aspect in the term ‘partnership’ is sharing concept (Victorian Council of Social Services).

Keast et al. (2007) simply explains the horizontal integration continuum of cooperation, coordination and collaboration (Keast, Brown, & Mandell, 2007). They comment that the more the line of horizontal integration continuum moves to the left, the more limited connection and lower intensity, conversely, the more the line of horizontal integration continuum moves to the right the higher connection and intensity. In addition, the figure shows that coordination is in between cooperation and collaboration in which coordination has medium connection and intensity.

2.3 The importance and benefit of working in partnership

Why organizations or people work in partnership and how health status among other sectors and dimensions so that the partnership is required. This section discusses the importance of partnership and what benefit can be gained from building partnership. Hancock (1993) stresses three ecological models which describe the relationship between health, human development and the community. According to the model, it is a multi factors. Health is not a single factor; the control of health is often outside health sector. Health relates to society, economy, and environment (Hancock, 1993). The relationship between health and community eco-system can be seen as figured out below. This model is also called healthy city model (Duhl, 2005; Hancock, 2006)

Therefore, as health is not a single factor and the control of health is often outside health sector, building partnership is necessary. The purposes of partnerships are to share resources, funding, and experts in facilitating, advocating for the success of the program (Bauld & Langley, 2010; McQuaid, 2000). With building partnership it is expected available resource can be used effectively and efficiently (McQuaid, 2000). McQuaid (2000) argues that the main advantages of partnerships are resources availability, effectiveness and efficiency, and legitimacy (McQuaid, 2000). Hamdi and Majale (2005) explain that the aims of partnership are to gain mutual access or resources; to support good governance, transparency, accountability and democratization of decision making; to increase the scale of impact; to make agendas of inter-sectoral actions; and to correlate practical and strategic programs which are frequently hard to involve one single player (Hamdi & Majale, 2005).

Roussos and Fawcett (2000) comment that people or organizations generally need partnership due to several assumptions: the goal of the program can not be achieved by any individual alone even group; participants should include different individual and groups representing the group and areas or concerns; and making consensus among partners (Roussos & Fawcett, 2000). Audit Commission (1998) explains that building partnership to address difficult matters is easier than doing alone (Hamdi & Majale, 2005). Fear and Barlett (2003) argue that the benefit obtained from building partnership is to improve the use of scare resources effectively (Hamdi & Majale, 2005). Bauld (2005) mentions that some partnerships working are mandatory to work together to access funding while some others are based on the perceived needs to coordinate activities (Hamdi & Majale, 2005). Partnership in this research focuses more on the perceived needs that aim to coordinate programs and challenges faced.

Different from definition explained by Green at al. (2009), they explain that partnerships for health especially at the local level are important for three reasons. First, people from varied sectors could share a general concern in their city. Second, they have more opportunities for meeting and working compared to the national level. Third, the nineteenth century, public health movement had established such partnership. Barton and Tsourou (2000) mention that, inter-sectoral cooperation aims to optimize the capital use and to gain maximum synergy and efficiency. Cooperation between health sector, urban planners and other sectors at local government, as well as private sector and universities are required to address urban health problems effectively (Barton, Tsourou, & World Health Organization. Regional Office for, 2000). Booth et al. (2001) commented that building partnership with other stakeholders particularly with community is essential. It encourages a sense of hopelessness, obedience and fatalism and reliance; it does not transfer important expertise, understanding to the public members; and it does not support possession (Barton, et al., 2000). At least there are three benefits gained in building partnership which are partnership will keep, sustain and ensure the sustainable development; partnership offers opportunities for vulnerable groups including poor people to make alternative options on their live; partnership will save funds and other resources; and also partnership will encourage others to involve in solving the problems (Barton, et al., 2000).

Partnership is not something new. MacArthur (2002) wrote a book published by WHO entitled Local environmental health planning: guidance for local and national authorities. One of the important quotes about the partnership is that “Action taken at local level is now universally recognized as a requirement for the true achievement of global improvements in environmental health. Municipalities at he form of government not only closest to the population but also often the most effective at working in partnership with community stakeholders: a prerequisite for any initiative on environmental health action” (MacArthur, 2002). This statement indicates that working in partnership is crucial.

As health is multiple factors, it optimally can be achieved when sectors work together. Cities can not work and act alone; they need other people or institutions. This has been recognized by Mayors and senior political representatives of European cities as pointed on International Healthy Cities Conference held in Zagreb on 15-18 October 2008 (WHO, 2009). Similarly, the Athens Declaration for Healthy City cited “Health is promoted most effectively when agencies from many sectors work together and learn from each other” (Av amopoulos & Asvall, 1998). Furthermore, the declaration also pointed that “health is everyone’s business; we pledge our political support for unlocking the health potential of all stakeholders in our cities’ future” (Av amopoulos & Asvall, 1998). Both these declarations emphasize the importance of partnerships because health is everyone business.

The spirit to build partnership with others is also in line with the report and documentation of the technical discussion held in conjunction with the 37^th meeting of CCPDM in New Delhi, August 31, 2000. Participants and member countries agreed that political commitment, partnership between government and non government organisations and also community participation were necessary for the success of healthy settings-types projects. They had to build an effective coordination mechanism among different stakeholders in healthy setting projects and programs (WHO, 2000). Member countries in South East Asia region generally were facing challenges in relation to funding support and human resources. They require external support to strengthen the healthy city and other healthy settings to promote health. A number of recommendations resulted from the meeting to strengthen the implementation of healthy settings in the countries of South East Asia region included members countries have to provide priorities to strengthen human resources capabilities for managing healthy setting projects; member countries have to advocate inter-sectoral action for the primary health care approach at the district level (WHO, 2000).

In short, working in partnership is essential. It is more an effective way to overcome a specific goal than each partner operating separately. Building partnership resources, risks and benefits can be shared to all partners member. The next section reviews a variety of theories and models of working in partnership.

3. Theories and models of partnership

This section explains social capital theory that may be relevant and helpful in directing organizations working in partnership. Some models of partnership are also provided. Social capital theory is one of the theories offered by Gillies (1998) to foster partnership working (Balloch & Taylor, 2001; Gillies, 1998). Putnam (1996) and Coleman (1990) defined the social capital as follows (Kreuter & Lezin, 2002).

Putnam (1996) stated that social capital is “the features of social life-networks, norms, and trust-that enable participants to act together more effectively to pursue shared objectives (whether or not their shared objectives are praiseworthy is, of course, another matter”.

Coleman (1990) defined social capital “by its function. It is not a single entity, but a variety of different entities having two characteristics in common: They all consist of some aspects of social structure and they facilitate certain actions of the individuals who are within the structure. Like all forms of capital, social capital is productive, making possible the attainment of certain ends that would not be possible in its absence. Like physical and human capital, social capital is not completely fungitable with respect to certain activities. A given form of social capital that is valuable in facilitating actions may be useless or even harmful for others”.

Therefore, social capital relates to networks, norms, and trust as illustrated by Rinehart et al. (2007, p.7) on Successful Collaboration Wheel. It enables to facilitate communities or organizations’ activities involving cooperation, coordination, and reciprocity (Gillies, 1998). “Cohesive social relationships, social civic action, and social trust” are three themes of social capital as solution to realize social regeneration and development of an effective community (Balloch & Taylor, 2001, p.195). Hence, great level of trust, positive social norms and many overlapping, intractable, and different horizontal networks for fostering communication and exchanging information, though and technical assistance, will survive in which social capital stock are high. Thus, trust is to be a core for building a partnership.

Cornwall, Lucas, Pasteur (2000) note two approaches of an effective partnership as described on their paper entitled Introduction: Accountability through participation, developing workable partnership models in the health sector. First, John Milimo recognized a community-based organization in Zambia, the Health Neighborhood Committees (NCs), as an institution facilitating partnerships between health service providers and consumers. He argued that those committees have played an important role to ensure fair access to health services. These also have created a sense of belonging over facilities of health. Learning from these committees, these could be developed to articulate problems associated with public interests on health and other relevant issues. Second, Adebiyi Edun also recognized the potential benefit gained by giving greater responsibility to community-based organizations. He proposed that community-based organizations have to take a part in the implementation of the project monitoring and evaluation and more stringent in project modification design. This could improve a sense of ownership and ensure the potential for sustainability (Cornwall, Lucas, & Pasteur, 2000). John Milimo and Adebiyi Edun provide me a useful framework in fostering partnership effectively. However, they did not explain what departments and sectors are involved in the organizations, how the organizational structure works and other factors influencing the effectiveness of the partnership including capacity building and incentive or salary system. The more organizations involved in partnership the more complex of problems the partnership faces.

After explaining social capital theory, this paper provides a variety of models of partnership working. Generally, the purposes of health actions are to reduce and address diverse inequalities in health. On the right hand side, it explains that determinants of health are multi-complex including socioeconomic and environmental issues while on the left hand side, it describes that to address those problems, working in partnership involving multiple sectors including public sector, private sector, voluntary and community sector partners are essential. Audit Commission (1998) as cited from Boydel and Rugkasa (2007) explains that working separately, for some cases, of one another sometimes is appropriate. However, when organizations and institutions face intractable challenges which they cannot solve on their own capacity, they require forming partnership. Once organizations need to form partnership, potential partners collaborate with one other. They try to connect to other networks outside the partnership. This shows in the first cycle in the figure moving from left to right. Partners begin to know, learn and share each other and this will result mutual trust and respect. This is shown in the second circle of the figure. After understanding, knowing each other, partners probably begin to take different actions. Players find that this partnership helps to meet the needs of their organizations. The last circle shows the obtained impacts from building partnership. They may include effectiveness of project or programs, improved health services or strengthening of communities capabilities (Boydell & Rugkåsa, 2007).

Sam Unom assessed the community participation and accountability development under the DFID’s aid. This was basic health services project developed in Nigeria in which it adopted an approach emphasizing on a social action fund. Local community groups obtained support from The Benue Health Fund to develop program concerning health-related projects. This aid was donor response of the Benue Health Fund to the financing difficulties faced by the local community groups. Nigeria was a country that was facing various problems for instance unstable political conditions and frequently unsupportive policy system; a high bureaucratic system with centralized government; limited capacity of manager to encourage community participation. To address a range of those problems the project developed mechanism to support community participation that may present lessons learnt for practice in other similar conditions (Cornwall, et al., 2000). This is a useful partnership model for others. However, it did provide in detail how the specific mechanism was running, who was involved and what the significance of the mechanism gained after being established.

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