Collaboration is difficult to establish and maintain. First, stakeholders often have differing goals or understanding of the problem, which leads to disagreements and a devaluing of others' preferred strategies and approaches. Partners who share responsibility for naming and framing the problem may find it easier to bridge those differences. Having common goals makes it easier for stakeholders to see their potential contribution to healthier communities.
Second, stakeholders often focus narrowly on only a few of the many factors that contribute to the problem. They typically use interventions to address these through familiar channels of influence; yet improving population health requires comprehensive and coordinated approaches that address 1) multiple personal and environmental factors (eg, knowledge and skills, access to services and support, policies and living conditions), 2) multiple sectors (eg, health, education, government), 3) multiple ecologic levels (eg, individuals, organizations, communities, broader systems). Stakeholders are more likely to see the work they do as particularly needed; thus, shared responsibility among organizations working in multiple sectors is rare.
Third, working at multiple ecologic levels is challenging. Different determinants of health have different areas of policy action and related actors (eg, Medicare, federal officials; air quality, regional actors; school nutrition, local people). Few partnerships coordinate collaborative action across multiple levels. Fourth, working together requires flexibility on the part of stakeholders' organizations and those who fund them. Yet many nonprofit organizations and governmental agencies have policies that limit their capacity to share resources and responsibilities.
Fifth, measurement of accomplishments is also a challenge. Many initiatives do not have accurate or sensitive measures of success at the level of the whole community. Changes in the community or system — the unfolding of new programs and policies — need to be measured to see what was actually implemented and its contribution to more distant population-level outcomes. The merit of longer-term efforts is difficult to assess and adjust to without such measures of environmental change.
Sixth, incentives for population-level improvement, such as outcome dividends, are rare. Without effective incentives for improving population health, the time and effort of collaborating with partners may go unrewarded. Working together across organizations is challenging because of competition for limited funding. The prevailing contingencies of reinforcement help secure discrete resources for individual organizations, not groups of organizations to improve population-level outcomes for which responsibility is shared.
Seventh, our knowledge of how to effect change in communities and systems to produce substantial improvements in population health is limited. We need a better understanding of how key collaborative processes, such as action planning or community mobilization, can yield environmental changes that will improve population health. Stakeholders may lack the experience or training required to make the community or system changes needed to affect public health.
Finally, public health has promoted best practices or programs that work as a way to ensure that the most effective approaches are implemented. The problem is that evidence-based programs are typically tested with small numbers of individuals and evidence of comprehensive and context-appropriate strategies that actually improve population health is rare. Researchers and practitioners have begun to reorient their efforts to population health using frameworks and related processes (9