MULTI-LEVEL COLLABORATIVE GOVERNANCE: THE CANADIAN HEART HEALTH INITIATIVE
Vol. 39, Issue 4, Dec 2009
Introduction and context
The evolution in democratic regimes from government to governance has been extensively documented. The view expressed is that society has become so complex that the formal, structured processes of government are no longer adequate to tackle major public policy issues in isolation. There are an increasing number of “wicked problems” to address, in which a multiplicity of factors, interests, and players are interwoven.1 These issues are beyond the capacity of any one government to resolve on its own. What is needed, according to this view, is the active involvement of civil society, including the voluntary and non-governmental sector, universities, journalists, professional associations and the private sector, as well as governments. Students of the policy process have developed the concept of “collaborative governance” to describe this phenomenon in which groupings are formed of many players to address a common public policy issue. Collaborative governance has been defined in several ways. According to Chris Ansell and Alison Gash, collaborative governance is: “A governing arrangement where one or more public agencies directly engage non-state stakeholders in a collective decision-making process that is formal, consensus-oriented, and deliberative and that aims to make or implement public policy or manage public programs or assets.”2 A somewhat broader definition is offered by Mark T. Imperial who suggests that “Governance refers to the means of achieving direction, control, and coordination of individuals and organizations with varying degrees of autonomy to advance joint objectives.”3 In general, what characterizes this phenomenon is a coordinated yet non-hierarchical, non-authoritarian form of decision making, involving governmental and non-governmentl articipants working toward a common objective.
Collaborative governance, therefore, seems to mirror the 21st century realities and likely will continue to do so. It is, therefore, important to attempt to understand the workings of these “new” governance models, and there is a substantial amount of literature which attempts to do so. Looking at this literature, one cannot fail to be impressed by the high level of diversity and complexity of these processes. What also emerges is a perspective on how challenging it is to implement collaborative governance and the many factors that need to be in place for these arrangements to succeed. This no doubt accounts for the fact that collaborative governance arrangements, in many instances, have not achieved the results that were intended.4
Moreover, the level of complexity – and therefore the risk of failure – is greatly increased when multi-level collaborative governance initiatives are attempted. In the case of Canada, a national collaborative governance that is meant to have an impact “on the ground” often needs to involve the federal and provincial/territorial governments, and local governments, as well as non-governmental structures – voluntary sector organizations, professional associations and the like – that are themselves sub-divided in national, provincial and local chapters. In other words, the multiple levels of government are paralleled by multiple levels in the non-governmental sector.
It is in this context that the Canadian Heart Health Initiative (CHHI) can be looked at as an example of multi-level collaborative governance. Collaborative initiatives are quite common in public health, especially in the health promotion and disease prevention functions of public health.5 Since this is an area in which both the federal and provincial/territorial governments have a legitimate role,6 and where the involvement of civil society is needed to ensure “traction” at ground level, collaborative initiatives have become “a way of doing business.” The key question we wish to examine is how a number of diverse organizations, each independent within its own sphere, can manage to coordinate their actions in pursuit of a common goal. What is the initial impetus that brings them together, and the common bond that keeps them together? What structures, collaborative practices and leadership competencies do they use to achieve coordination and meaningful results? Perhaps more important, what challenges do they encounter, and how do they overcome them, if indeed they succeed in doing so? And most important of all, what can we learn from their successes and failures?
The CHHI was chosen as the basis for this study because it had a significant (20 year) timeline; is part of our recent history; had numerous outputs; and involved federal, provincial, and local governments, and numerous players from civil society. The premise of this paper is that while the CHHI made a significant contribution to the field of heart health promotion in Canada, it ended before it could have the impact that was intended and that governance issues were a key factor in its premature demise. The paper will first describe the analytical framework and methodology that will be used; provide an overview of the CHHI; and examine various facets of the initiative using the categories of the analytical framework as guides. Based on this analysis, the paper will offer a number of preliminary conclusions and raise some questions for further investigation.
Analytical framework and methodology
A number of frameworks have been proposed in the literature to deal with collaborative governance, policy networks, policy coalitions and related concepts, many of which were developed to apply to a specific case or cases. The challenge is to apply a conceptual lens that is general enough to encompass the various manifestations of collaborative governance, without being cast at such a high level of abstraction as to become difficult to apply to real-world cases. For this, the framework provided by Ansell and Gash is useful.7 After studying numerous cases, across several policy sectors, in the United States (US) and in many other counties, the authors propose a framework containing four broad categories of variables: starting conditions, institutional design, collaborative process, and facilitative leadership. Each of the above categories is very broad and needs to be disaggregated further. But at the same time, each presents a “lens” through which to examine cases of collaborative governance and extract key issues. We will take each of these categories in turn, briefly discuss their significance drawing from pertinent scholarly literature, and seek to apply them to CHHI. The categories will be used as general guidelines, to be applied flexibly. In some cases, we will adjust the categories to take into consideration factors that are either missing or under-emphasized in Ansell and Gash. In particular, we will adjust the framework to underline the non-linear relationship of the factors and to take better account of the federal reality of Canada. The framework, amended from Ansell and Gash, is represented below as Figure 1.
The methodology followed for the examination of the CHHI was a review of the published literature followed by seven semi-structured but open-ended interviews with key informants. The process evaluation of the demonstration phase, prepared by the Conference of Investigators of Heart Health, was particularly useful for our purposes.8 The interviews were of key players from the federal government, provincial governments, voluntary sector organizations and universities who had been involved in the initiative from the early stages and were therefore in a position to share important information and insights. With regard to terminology, in this paper we will use coalitions, collaborations and networks inter-changeably, recognizing that distinctions can be made between and within these broad generic terms.9
The Canadian Heart Health Initiative
The CHHI was initiated in 1986 in the wake of a paper produced for federal-provincial-territorial deputy ministers of health entitled Promoting Heart Health in Canada.10 It was designed “as a strategic linkage model employing coalitions to achieve partnerships and collaboration within and across sectors, and across national, provincial and local levels.”11 Its long-term health goals were to:
Its short-term health goals were to:
In addition, the CHHI established health system goals, which were to:
A multi-level approach was taken for the CHHI, involving the federal government, through Health Canada, provincial governments (territorial governments did not participate), and local communities. It followed a “cascading” model in which broad directions were set at the national level; provincial-level coalitions were struck to co-ordinate activities in the province in question; and projects were carried out at either the provincial or local levels. There was also an important international dimension, as representatives of the CHHI participated in international conferences to share information about the initiative (at that time, Canada was seen as a world leader in the area of health promotion), and to learn from what other states were doing. Furthermore, the CHHI followed a partnership approach, in which it included voluntary sector organizations and NGOs at all levels. The various levels of the CHHI and the respective roles of the partners have been represented below.
Government of Canada (Health Canada) role
Voluntary sector/NGO role
Initial funding was provided by Health Canada primarily out of the National Health Research and Development Program (NHRDP), and supplemented by discretionary funding. There was a requirement for matching funding by the province which was reflected in bilateral agreements on a province by province basis. In addition, there were in-kind contributions from NGOs and the private sector.
There were five distinct but overlapping phases of the CHHI:
Unfortunately, there has been no evaluation of the initiative as a whole. However, there is a process evaluation on the demonstration phase, which is seen as the “backbone” of the initiative.18 From this we know that the initiative spawned 311 projects in all, amounting to a total expenditure of $36 million. Of the six strategies that were eligible to be funded under this initiative (public education; community mobilization; healthy public policy; strengthening preventive health services; research and evaluation; public health system leadership), 60 percent of the projects and 62 percent of the expenditures were on public education projects mostly related to modifiable risk behaviours.19 The next most frequently-used strategy: community mobilization, accounted for 17 percent of the projects.
The CHHI ended in 2006, when the funding program on which the initiative depended at the federal level was not renewed. (By this time, NHRDP no longer existed, having been absorbed within the Canadian Institutes for Health Research). The initiative can point to a long list of accomplishments, including: provincial heart health risk factor surveys; several scientific papers on subjects related to heart health; and many community coalitions that continue to exist to this day. However, the initiative did not reach the deployment stage, as had been planned from the beginning.20 Since the first five phases could be seen as building blocks towards an implementation strategy, not reaching this phase is significant. The demonstration projects, important as they were, were meant to generate knowledge about the effectiveness of various interventions, which would then be incorporated into a full deployment stage. The fact that most demonstration projects were public awareness projects, which many health specialists would consider the lowest-hanging fruit in the field of health promotion, suggests the initiative ended before reaching full maturity. Second, and closely related to the first point, the CHHI ended before achieving its overall health system goal of fully integrating heart health into the public health infrastructure of Canada.21 What follows will argue that governance factors were a key determinant – albeit not the sole factor – of the CHHI not completing its mission.
Ansell and Gash indicate starting conditions “set the basic level of trust, conflict, and social capital that become resources or liabilities during collaboration.”22 Some authors have referred to a similar notion as “predisposition.”23 Out of this come relevant issues such as a previous history of conflict or collaboration among the players. The existence of incentives, such as the possibility of accessing funding, is also often a strong motivator. Perhaps even more fundamental in setting the stage for a collaboration is the existence of a common goal and a common set of beliefs. There must be what one observer has called “common… agreed or clear sets of aims as a starting point in collaboration.”24 This is key as an initial motivator, as well as the “bond” that holds a coalition together once it is established.25 Organizations seeking to act in concert with others will almost inevitably encounter differences in corporate culture, internal priorities, ways of operating and the like. Having a common set of aims or beliefs can be a very potent force in overcoming the problems that surface in a coalition or network.26 Furthermore, the recognition of the mutual inter-dependence of the players to achieve these aims is a critical part of starting conditions.27 Finally, the common aims and beliefs of the players in a collaboration should not be seen as static. Although, as Sabatier and Jenkins-Smith have argued, core beliefs will be resistant to change, it is to be expected that what they call “secondary” beliefs, as well as the aims of a collaboration, will adjust as the collaboration advances and generates policy learnings.28
As applied to the CHHI, although requiring more systematic validation, there is good reason to believe that the holding of common beliefs and aims was one of the key factors in bringing the players together. 1986, the year of the initiation of CHHI, was a major turning point in the evolution of public health in general, and health promotion in particular, in Canada and internationally. This was the year of the Ottawa Charter on Health Promotion, a charter developed at the first International Conference on Health Promotion, held in Ottawa, which signalled a new approach to health promotion. This approach was committed to dealing more directly with the determinants of health, and which saw health very broadly as “physical, mental and social well-being,” and as a consequence of public policies both outside and inside the health sector.29 Furthermore, at about the same time, Achieving Health for All was released, often called the Epp Report after the minister of health of that time, reflecting a similar approach as the WHO document and applying these principles to the Canadian context.30 The focus on a population approach to prevention of disease, community-level interventions, and partnerships is seen as signalling a new approach to public health.31 These developments signalled a major shift in thinking in the area of public health in Canada.32
It was in this environment that the CHHI was conceived. It was initiated by a small number of public health professionals in Health Canada and provincial governments who believed in the principles of the Ottawa Charter and the Epp Report and sought ways to translate these principles into practical reality. A report developed for federal-provincial-territorial deputy ministers of health, titled Promoting Heart Health in Canada, articulated this approach and became the framework for the initiative.33 There were undoubtedly other incentives for participants to join this collaboration, probably the chief one being the possibility of accessing federal funding. But this does not appear to have been the major factor. The national consultation exercise which took place in the early stage confirmed a “broad national consensus… on the goals and strategies” of the CHHI.34 Moreover, the key informants interviewed stressed that the leading actors from the federal and provincial governments were, as one put it, “of one mind” about what was to be accomplished and how.
More needs to be learned about the extent to which this set of beliefs penetrated all levels of the CHHI and whether it was maintained throughout its existence. However, from all indications, this was more than simply a “coalition of convenience.” It was a collaboration in which the leading players, and the broader public health community, were united by a shared belief in both the goal and the methods in achieving that goal.
Ansell and Gash describe “institutional design” as “the basic ground rules under which collaboration takes place.”35 There are many issues that can be considered in this context, such as frequency of meetings, optimum numbers of players, the existence or absence of dedicated support staff, the role of the chair, and so on. All are important issues which need to be taken seriously. In this paper, however, we will attempt to focus on the more “macro” issues: What are the structures of decision making? Who are the players involved and what mandates have they been given? And what are the power relations within the group? Questions related to funding will also be included in this discussion, since these formed a critical part of the decision making of the CHHI. How the inter-governmental relations were managed for this initiative will also be included in this section, since it was a critical factor in the institutional structure of the initiative.
From the literature on the governance of networks and coalitions, there appears to be no ideal model that will work best in all cases. Which model or style will be most effective will depend a great deal on a number of contextual factors.36 Certain key points emerge, however. The importance of inclusiveness is highlighted, not just for tactical reasons, but also because of the need for “collective, interactive discourse.”37 Transparency and fairness are also seen as important. A related question is the perceptions of power imbalances within a collaboration. Participants need to feel that they are being treated fairly; that there is a level playing field; and that they have a role in determining the broad directions of the network.38 The need for good communication is also critically important,39 as is flexibility, to ensure the ability to make adjustments to changing players and circumstances.40
Particular attention is given to the question of funding. There are several aspects to this question. The first is the question of the availability of funding, the importance of which is quite obvious. Also significant is the question of the funding source – does it come from only one of the parties, or from more than one source? Multiple relationships will tend to “equalize” power, and set up more constructive relationships, whereas reliance on only one source for funding could create some dependencies that have a negative impact.41 There is also the question of short-term versus longer-term funding, which can also have an impact of internal dynamics. Mitchell and Shortell, among others, make the point that short-term funding can have a detrimental impact on partnership stability and sustainability.42
Also important is the question of how to accommodate the involvement of different orders of government in a collaboration. As mentioned earlier, the participation of two orders of government in a collaboration creates an additional level of complexity to what is already a complex undertaking. Mark Imperial makes the useful point that different types of collaboration can co-exist within a single policy network 43 It seems fair to assume that the greater the complexity of a policy network, the greater the likelihood that this will occur. In this context, multi-level collaborations would seem more likely to encompass different types of collaboration, perhaps to the point of having networks within networks. It seems reasonable to posit, for example, that in a federal system of government, intergovernmental partners relate with each other in a way which is different from their interactions with other members of the coalition.
In Canada, because of overlapping jurisdictions in public health, as mentioned earlier, mechanisms are necessary to manage federal-provincial/territorial relations within the collaboration in this domain. As some recent studies have demonstrated, federal-provincial-territorial relations can operate at different levels within the same policy context. Johns, O’Reilly and Inwood have made an important distinction between intergovernmental relations (IGR), which operate at the more strategic level and is usually handled by central agencies, and intergovernmental management (IGM), which is carried out by the program areas in government. As Johns et al. have demonstrated, IGR and IGM may not share the same agendas, and in many cases, IGR officials may feel that those involved at the program level are too inclined to collaborate with their counterparts.44 This dynamic is apparently not unique to Canada; Martin Painter has made the same observation with respect to Australia.45 We will return to this issue in our discussion of the CHHI.
The first point that is striking about the CHHI from an institutional design perspective is its lack of mandate at the federal level, and its lack of sanction from a federal-provincial-territorial (FPT) perspective. The Health Canada officials who were involved with the initiative did not see the need – and may have deliberately avoided – seeking policy authority through a memorandum to Cabinet (MC). They may have felt that their mandate could be drawn from the National Health Research and Development Program, but in actual fact, the CHHI was far more than a research program. More likely, they were concerned that going through the formal process of seeking a Cabinet mandate may have restricted their marge de manoeuvre or erected road-blocks in their attempts to launch a new and innovative initiative. Whatever the reason, the practical consequence of this was that Health Canada officials were participating in CHHI without a specific mandate to do so, and outside of formal scrutiny from within the federal government. This was compounded by the fact that the CHHI did not report to an established FPT committee. The health sector in Canada is characterized by an elaborate FPT structure, in which inter-governmental committees and processes normally (but not always) report to an FPT committee at the deputy minister and/or the ministers’ level. In this case, the CHHI functioned outside the “orbit” of this committee structure, and therefore without the sanction or scrutiny of a senior FPT forum. Using Johns et al.’s useful distinction, therefore, this is clearly a case where inter-governmental relationships were handled at the program level, not the strategic level. Although the initiative began with an FPT deputy ministers’ working group, the CHHI was not established as part of an FPT agreement or formal process. It would have been largely invisible to those dealing with inter-governmental relations at the more strategic level. This is an important point to which we will return later.
Consistent with its nature as a collaboration, the CHHI’s decision making was consensus- based, de-centralized, and flexible. The primary governance was established, not by an over-arching framework agreement, but rather by a series of bilateral agreements between the Health Canada and individual provinces. The agreements were negotiated on a staggered basis, starting with Nova Scotia followed by each of the other provinces at a time of their choosing. The agreement, developed collaboratively by Health Canada and the province in question, was then submitted to the National Health Research and Development Program, housed within Health Canada. They were drafted as research projects for the purpose of developing knowledge about interventions at the community level related to heart health. Once received by NHRDP, they were sent for peer review to ensure the scientific validity of the methodology. When approved, funding was made available, with the condition that this funding be matched by the provincial government in question. Consistency was achieved by the fact that once the first proposal was reviewed and approved, it was used as a model for agreements with the other provinces.
At the national level, the CHHI was led by the Conference of Principal Investigators of Heart Health, which met at least annually. This committee did not seek to oversee what was taking place at the provincial level – rather, its function was primarily to establish the science behind the CHHI, discuss what additional knowledge products were needed, and strategize about next steps. Working groups were created and studies were commissioned on a range of topics related to heart health. Beyond this, a forum called the Canadian Heart Health Network would be called approximately once or twice a year to provide an opportunity for information sharing and skills development.
From an inter-governmental perspective, the relationships seem both collegial and science-based. Generally, the program leads for Health Canada and for provincial governments were health professionals, usually chief medical officers of health. This provided a common language for the participants to use. It might fairly be said that the usual federal-provincial diplomacy was supplanted by scientific and technical issues that formed a common base for the discussion and for the relationships between the lead players. The fact that the CHHI was characterized as a research initiative would have reinforced this tendency.
Notwithstanding the collegial nature of the relationships, there were power differentials within the CHHI. In the first instance, Health Canada took a leadership role through its access to funding. This enabled Health Canada officials to set the parameters around the funding, and therefore the initiative as a whole. It also appears that Health Canada officials provided a great deal of the intellectual leadership for the initiative. Neither of these factors seemed to have caused any apparent inter-governmental friction. On the contrary, Health Canada’s leadership, along with its funding, was welcomed.
More fundamentally, there was an important power imbalance between governments and the non-governmental sector. The Heart and Stroke Foundation of Canada was identified as a national partner, but did not have the same status as a government. The power differentials were likely even greater at the provincial and local levels. The fact that federal and provincial/territorial governments provided most of the funding for the demonstration projects would have put them in a stronger position than NGOs, whose role was more related to delivery than to direction-setting. This is somewhat at variance with the notion that players in a collaboration should be on a “level playing field.” Yet, power imbalances are often difficult to avoid, particularly when governments are involved.46 Lawrence O’Toole has observed that networks “must combine the vertical elements of hierarchy and the horizontal components of functionally-induced interdependence.”47 In view of these power imbalances, the CHHI might be seen as a sort of collaborative governance “hybrid.” If so, it is probably in good company. As Innes and Booker have observed, collaborative governance in its “pure” form, happens only rarely, if at all.48
At the provincial/territorial level, the decision-making structures were both flexible and highly variable. By the terms of the funding agreements mentioned above, each province was required to form at least one coalition to carry out the demonstration projects. Eight of these operated at the provincial level, 33 at the local level. The composition and functioning of these coalitions differed from one case to another, and in some instances, their roles evolved as the process matured.49
From this review of the CHHI’s institutional design, therefore, one would draw the following inferences:
The implications of these observations for the CHHI will be discussed later in this paper.
The collaborative process variables go beyond the structural features of a collaboration to ask: “what makes the collaboration work?” These factors can operate at both the level of individuals and at the organizational level. In the former case, there is a considerable emphasis in the literature on the importance of trust, and particularly trust-building, among the players of a coalition.50 Other factors which have been identified are the importance of direct communications, intermediate outcomes to provide some short-term movement to a process, and shared understandings of the initiative through mission statements and strategic plans.51
At the organizational level, participants in a coalition need to find a balance between their needs as an organization, and the role they play as a partner in a coalition.52 Network members, particularly voluntary sector organizations and NGOs, in the first instance, must still strive to ensure their survival as an organization.53 How this balance is struck is a central issue. An important concept in this context is congruence between the objectives of the individual organization and the objectives of the coalition. In an ideal world, the organization, by pursuing the needs of the coalition will be pursuing simultaneously their own organizational objectives. An NGO which champions for example, cancer prevention, may be very supportive of an initiative which addresses modifiable risk factors relating to heart health, because cancer and CVD share many of the same risk factors (tobacco use, physical inactivity and unhealthy eating.) At the same time, however, that agency depends on fund raising, and will likely want to avoid losing its visibility in an initiative which is based on another disease group, or even an initiative that is more generic in seeking to address common risk factors. Unfortunately, there appears to be very little research on this issue.54 Questions remain about what might be the “tipping point” in an NGO’s willingness to support an initiative which might be aligned with its objectives, but may run contrary to its need to survive. A related question might be whether NGOs in the same coalition consistently see themselves as collaborators or whether there are times when they see each other as competitors? Clearly, this is an area which warrants more attention.
There are a range of other issues which operate at both the individual and the organizational levels. For instance, it is not necessarily clear how the players maintain their level of commitment as a collaboration evolves. As discussed earlier, a set of shared aims and beliefs is fundamental to a collaboration. However, shared beliefs alone may not be sufficient to sustain a coalition when it almost inevitably runs into challenging issues.55 As participation in a coalition is usually voluntary for the participating individuals and organizations, the benefits of participating must outweigh the costs for players to stay on board.56 What these factors are will undoubtedly vary greatly depending on individual circumstances.
Applied to the CHHI, certain key issues emerge. At the inter-personal level, trust certainly appears to be one of those factors. As previously stated, the CHHI was initially brought about by a relatively small group of like-minded individuals who knew each other from previous capacities. As medical officers of health, they shared a common training, understandings, and approaches. A number of interviewees also pointed out that while the leaders were strategically placed within federal and provincial governments, their involvement was driven by their personal and professional interest and commitment to public health, rather than by the formal positions they occupied within their respective organizations. Indeed, because they were for the most part below the level of deputy minister, a part of their role was to advocate within their respective organizations for support, including financial support.
Another factor which was important was the achievement of “intermediate outcomes.” The phased-approach of the CHHI might well have built in a sense of momentum and provided encouragement for the players to carry on. The fact that the first two phases: to set the overall policy direction and to conduct the heart health risk factor surveys, were conducted fairly quickly may have contributed a sense of positive movement. Several scientific reports from working groups assigned to various issues were also produced at different stages. Finally, the demonstration phase was focussed on projects, primarily at the local level, which would have given a tangible sense that the initiative was producing outputs and therefore helped to fuel the process.
At the inter-organizational level, the picture appears more complex. As we have seen, the inter-governmental relationships do not seem to have been problematic. What is not clear is how the voluntary sector organizations and the NGOs balanced their own organizational interests with those of the CHHI. At the national level, since the Heart and Stroke Foundation of Canada was the “lead” non-governmental organization, and the initiative was about heart health, one can infer a considerable amount of congruence.
What took place at the community level is much less clear. Both the process evaluation of the demonstration phase and the situational analysis57 refer to “turf wars” having been a significant liability throughout the CHHI. This was also confirmed through interviews, although one key informant suggested that the conflicts may have been more of a problem in the earlier stages of the initiative. Unfortunately, there is no clear picture of what was behind these conflicts. From the information we have, it seems that these conflicts were primarily at the community level during the demonstration phase. Indeed, an initiative like this one, involving as it did hundreds of organizations, is bound to experience instances of internal conflict. There is some indication that the tension was between NGOs, as well as between the national, provincial, and local chapters within certain NGOs. However, a much more intensive scrutiny would be necessary before any firm conclusions could be arrived at. What can be said is that there appears to have been an absence of mechanisms to deal with these conflicts when they arose. Training was available in different forms in different communities, including in conflict resolution, group management, and team-building. In some cases, facilitators were provided to the projects.58 More broadly, however, there is no evidence of a deliberate, consistent approach to the management of conflict when it arose.
With respect to the factors related to the collaborative process, therefore, the CHHI presents a multi-faced picture. On the one hand, for the leaders of the initiative, one can observe strong inter-personal relationships among individuals who shared common beliefs and a common professional training. There were also a number of intermediate outcomes in the form of surveys, reports, studies, and projects that would have served to give encouragement to the participants and a sense of momentum. The duration of the initiative for a twenty-year period is an indication in itself that the collaboration was functional. At the same time, the existence of internal “turf wars” is indicative that there were weaknesses within the collaborative process. This may have been the result, as one interviewee indicated, of lack of clarity, or differences in perception, about roles and responsibilities. It could also be due to inadequate internal communications, conflicts about funding issues; interpersonal conflicts; or a combination of some or all of these. These are questions that require more in-depth investigation. At this stage, however, it can be said that the lack of a consistent and effective mechanism to deal with these internal conflicts was potentially damaging to the initiative’s effectiveness and sustainability.
A number of scholars have pointed to the importance of leadership in a collaboration. Roussos found that in surveys of individuals involved in partnerships, leadership was the most often reported internal factor.59 It seems clear that every coalition will need champions – sometimes called policy entrepreneurs, or policy brokers – to help define and articulate its mission, and to identify and seize opportunities that arise on the policy landscape.60 Furthermore, given the nature of a collaborative venture, a certain style of leadership will be called for, hence the use of the term facilitative leadership. As many of the partners will see themselves as equals, a rigid hierarchical model is not appropriate. This will be particularly the case in a collaboration involving different orders of government, each sovereign within its jurisdiction. This style of leadership is well-captured by Roussos et al. in saying that it is “a process of persuasion or example by means of which an individual (or leadership team) induces a group to pursue objectives held by the leader or shared by his or her followers.”61 Gilles Paquet goes further, and argues that modern governance requires “stewardship” rather than leadership.62 While the style of leadership more typical of a collaboration is of a subtler, more multi-faceted nature, in comparison to the “command and control” model, it nevertheless demands a high level of tenacity and single-mindedness to ensure the collaboration holds together and moves forward in achieving its goals. Huxham refers to this balance by saying that leaders of collaboration have to operate from two perspectives: a spirit of collaboration and what he calls “collaborative thuggery.”63
Scholars have made the important observation that collaborations generally evolve over time, and that the type of leadership needed will change as the coalition matures.64 Butterfoss has suggested four stages in a collaboration: formation, implementation, maintenance, and accomplishment of goals or outcomes.65 What might be needed at the formation stage to provide a vision and mission for a collaboration may not be the same skills as are needed at the implementation or maintenance stages. Whereas policy entrepreneurs might be needed for the first phase, given their ability to recognize and seize opportunities and to take personal risks, it is likely that the needs will shift more to policy managers in the more mature phases. The skills of the latter will be more given to sustaining the coalition and adapting as necessary to adjust to changing circumstances.66 Takahashy and Smutney argue that coalitions may contain the “seeds of longer-term partnership failure” if they do not adjust to these changing leadership needs.
Good leadership appears to have been one of the CHHI’s great strengths, and perhaps, from a long-term perspective, one of its weaknesses. From the published material, and confirmed through interviews, it is apparent that the leadership for the initiative was concentrated in a small group of individuals, and with one individual in particular, emerging as the central figure.
Throughout its evolution the leadership of the initiative at the national level revolved primarily around Dr. Andres Petrasovits, described by Riley and Feltracco as the “linchpin” of the CHHI.68 This characterization, with different terminology, was repeatedly emphasized both in the written material and in the key informant interviews. From all evidence, the leadership style of the initiative, was more “charismatic” – in the sense that there was a high level of dependence on one individual – than institutional/bureaucratic, and appears to have remained so for its entire duration. Moreover, there is little to suggest a shift towards a more managerial style as the initiative evolved. Although the commitment of Dr. Petrasovits and his colleagues is evident, the CHHI does not appear to have been “institutionalized” within Health Canada, which left it vulnerable when changes of personnel or priorities occurred within the department. It is perhaps indicative that the demise of the initiative coincided generally with Dr. Petrasovits’ unfortunate death. Other factors, of course, were also significant, in particular the termination of the NHRDP, the primary federal funding source. Another potentially relevant factor was an increased interest in “integrated” as opposed to single disease health promotion strategies, although the federal government continues to pursue both integrated and disease-specific strategies. While it would be difficult to weigh the relative importance of these factors, the lack of a transition from a charismatic style of leadership to a more bureaucratic style would need to be considered highly significant. There also appears to be a link between this point about style of leadership, and the earlier discussion about the CHHI’s weak mandate within Health Canada, in that both led to the same consequence, that is, with the initiative operating on the margins of the department.
Unquestionably, the leadership of the CHHI went beyond this small group of individuals at the national level. Leadership was needed at the provincial level for the risk factor surveys and to establish and maintain the provincial and sub-provincial coalitions in the demonstration phase, as well as the evaluation and dissemination phases. Given the large number of projects that were initiated as part of the CHHI, this also suggests quite a diverse pattern of leadership styles applied in a wide range of circumstances. What this pattern was, and what leadership styles emerged at the provincial and local levels are questions would need further exploration.
Our opening proposition was that factors related to collaborative governance played a major role in the CHHI’s premature demise and is consequent inability to realize its full mission. This is not to argue that the CHHI was a failure. On many scales, it made a very important contribution to the field of heart health, and health promotion in general. It was an experiment that was closely monitored, and sometimes emulated by other countries. As one key informant put it, “the initiative changed the discourse in Canada from heart disease to heart health,” a major accomplishment in its day, which eventually was carried to the global community. It commissioned several studies and reports that were very useful in their time and which are still pertinent today. Some of the “demonstration” projects proved themselves to be sustainable, and are still in operation in some provinces. Finally, the CHHI built platforms that were used in some provinces for subsequent health promotion strategies. At the national level, some have suggested that the Pan-Canadian Healthy Living Strategy, launched in 2005, could be considered part of the legacy of the CHHI, although this would require a very generous interpretation.69
However, as stated earlier, on the basis of at least two important criteria, the CHHI fell short. First, it did not get to the stage of full implementation (deployment), as had been planned. Second, it did not realize its objective of integrating heart health into the public health infrastructure across Canada. At least three factors related to governance contributed to this result. First is the lack of sanction and mandate. As we saw, the CHHI never achieved formal sanction from federal and provincial/territorial governments. This was a mixed blessing. On the one hand, this meant that the CHHI could operate free of constraints, which provided an opportunity for flexibility, innovation and experimentation. In this sense, it might be considered a good example of what Gilles Paquet has called “virtuous scheming.”70 Furthermore, the fact that it was outside the “strategic” inter-governmental relations discussions allowed it to avoid becoming entangled in the fairly acrimonious FPT disputes in the 1990’s relating to funding for health care. It might even be questioned whether the initiative would have been launched if it had sought formal FPT sanction. On the other hand, the lack of sanction and mandate also meant that the initiative could easily be ignored or forgotten. When the NHRDP funding, on which the CHHI depended for funding, ended in 2002, there was no formal agreement or mechanism on which to base a case for its continuation. There was no formal decision to end the CHHI, because there had been no formal decision to initiate it. The consequence was that it ended with a whimper, not a bang.
A related point is the question of leadership at the national level. As was discussed, the style of leadership adopted was facilitative, and quite concentrated around a small number of individuals, and one in particular. From all accounts, it was remarkably effective for many years, but there does not appear to have been a shift from a “charismatic” style of leadership, that is, one centred mostly around a single individual, to a more institutionalized/bureaucratic style. Again, this may be a two-sided coin. The visionary style likely kept the spirit of the initiative innovative and experimental, and was obviously highly effective in bringing key individuals together around a new initiative. However, the fact that the leadership was not more institutionalized meant that when the key individuals left the scene, for a variety of reasons, there was no bureaucratic structure in place to maintain the momentum of the CHHI and to take the initiative to the next stage. As with the point about lack of mandate and sanction, this leads to the conclusion that the initiative was not sufficiently anchored within Health Canada.
The final point related to the existence of “turf wars” among the participants. Many scholars have indicated the importance of having processes to deal with conflicts that will inevitably occur in a collaboration.71 In the case of the CHHI, it is not clear what was at the root of this problem nor at what level these conflicts occurred. What seems evident, however, is the absence of effective, consistent mechanisms to manage and resolve these conflicts once they occurred.
A counter-argument could be made that this assessment is too harsh, and that any government initiative or program with a twenty-year existence should be deemed an unqualified success. After all, programs with this shelf-life are the exception, not the rule. Furthermore, it could be argued that by attempting to “institutionalize” the CHHI, through a stronger mandate and FPT sanction and through a different leadership model, the initiative could have been robbed of its energy, creativity, and dynamism.
There is no doubt that the CHHI was a very innovative venture, which, as stated above, produced an impressive number of accomplishments and which had a significant life-span. However, it needs to be recognized that public health initiatives, particularly those attempting to make behavioural changes at the population level, require a long-term commitment. The best illustration of this point is found in the efforts surrounding tobacco cessation. The anti-tobacco strategies have been impressively successful in reducing tobacco use in Canada, but have taken over forty years to accomplish. Moreover, these efforts are still on-going, as evidenced by the fact that the Federal Tobacco Control Strategy was renewed in 2007 for another five years. The modifiable risk factors, aside from smoking, that the CHHI was attempting to address, physical inactivity and unhealthy eating, are at least as challenging as tobacco use, and perhaps even more so, and also require a long-term commitment if significant outcomes are to be realized. Seen in this light, twenty years is nowhere near sufficient. Moreover, although the incidence of cardio-vascular disease is decreasing for the moment,72 no one could seriously make the argument that heart health no longer needs to be addressed as an important public health issue in Canada. The incidence of cardio-vascular disease continues to be alarmingly high with the consequent impact on health care costs and lost productivity calculated at $22 billion (2000 dollars).73 Indeed, the federal government, through the Public Health Agency of Canada, is now funding a new initiative, called the Canadian Heart Health Strategy and Action Plan, to address this issue, which, unfortunately, does not seem to be building on the base established by the CHHI.
This is not to dispute the need to re-assess, review and adjust if necessary public health initiatives. However, if the need to address a public health issues remains, it is important to build on the platforms and processes that had previously been put in place when making the necessary adjustments. Yet the fact that the CHHI operated on the margins and was simply allowed to die after its funding lifeline was cut, did not provide for an opportunity for this conversion to take place in a systematic way.
It is also worth setting this issue in the current context of public administration in Canada. Donald Savoie has made the point about centralization at the federal government and the strengthening role of the prime minister and central agencies.74 One of the consequences of this would be to leave less “room” for initiatives lacking a formal mandate and mechanisms for oversight. Moreover, the current preoccupation with ensuring appropriate accountabilities would add further ammunition to the same trend. Indeed, any initiative lacking a Cabinet mandate would be very vulnerable in the strategic review exercises currently taking place within the federal government, assuming it could find a way to start up in the first place.
For public health practioners, some broad themes emerge from this research. Perhaps the most obvious is the importance of preparation. Multi-level collaborative initiatives, as we have seen, are inherently complex and have a high risk of failure. This serves to underline the importance of giving serious consideration to the governance aspect of a new initiative from the outset, rather than treating this as secondary to the “content” issue, be it heart health, cancer prevention, or healthy living in general. The second point, closely related, is about giving care and attention to the designaspects of a collaborative initiative. This involves finding an intricate balance between building an initiative on a strong platform of mandate and accountability, while at the same time retaining a measure of flexibility, in recognition of the fact that in a collaboration, decision making must be shared with others.
The next broad theme is the importance of nurturing a collaboration. The number of factors affecting a collaboration is very great indeed, and any one of those can negatively impact an initiative. This means that those involved will need to have the time and resources to monitor constantly the process and have the capacity to make the necessary adjustments. Collaborations will simply not run on “auto-pilot.” Chris Huxham has indicated that “those who want to make a collaboration work have to be prepared to ‘nurture, nurture, nurture’ them,” and must be prepared to do so on a continuous and permanent basis because “no sooner will gains be made than a thunderbolt…will come to disturb them.”75 76
Finally, there is the crucial issue about leadership, or “stewardship” as some would argue. The key players will need to inspire, motivate, and in some cases mediate, without losing track of the notion that the process belongs to all of the participants, not just to one or a few. This is a style of leadership that is both challenging and, one would argue, uncommon. Also, as the case of the CHHI suggests, the leadership skills that are required will shift somewhat as a collaboration matures, which brings us back to the notion of monitoring the process and adjusting as necessary.
All the above points serve to underline the difficulty and complexity of making collaborations successful. Yet challenging as they might be, collaborations, for the reasons given at the beginning of this paper, are a part of our world. They are clearly a fundamental part of public health in the 21st century. It is hoped that through a close examination of the CHHI and other similar initiatives, we will deepen our understanding of collaborations and improve the tools at our disposal to make them successful.
Claude Rocan is a Visiting Fellow at the Graduate School of Public and International Affairs, University of Ottawa. He was previously director general of the Centre of Health Promotion at the Public Health Agency of Canada.
1 O’Toole, Lawrence J.D. Jr. 1997. “Treating Networks Seriously: Practical and Research-Based Agendas in Public Administration.” Public Administration Review 57 (1), p. 46.
2 Ansell, Chris and Alison Gash, 2007. “Collaborative Governance in Theory and Practice.” Journal of Public Administration Research 18, p. 544.
3 Imperial, Mark T. 2005. “Using Collaboration as a Governance Strategy:Lessons from Six Watershed Management Programs.” Administration and Society 37 (3), p. 282.
4 Roussos, Stergios Tsai and Stephen B. Fawcett. 2000. “A Review of Collaborative Partnerships as a Strategy for Improving Community Health.” American Review of Public Health 21, p. 376.
5 Butler-Jones, David. 2009. “Public Health Science and Practice: From Fragmentation to Alignment.” Canadian Journal of Public Health 100 (1), p. I-1.
6 Wilson, Kumanan. “The Complexities of Multi-level Governance in Public Health.” Canadian Journal of Public Health 95 (6), p. 409.
7 Ansell and Gash, 2007, p. 550.
8 Conference of Principal Investigators of Heart Health. 2002. Canadian Heart Health Initiative: Process Evaluation of the Demonstration Phase. Ottawa: Health Canada.
9 Mingus, Matthew S. 2001. “From Subnet to Supranet.” In Getting Results through Collaboration. Ed. Myrna P.Mandell. Westport, Connecticut: Quorum Books, p. 36.
10 Federal/Provincial Working Group on the Prevention and Control of Cardiovascular Disease. 1987. Promoting Heart Health in Canada. Ottawa: Health and Welfare Canada.
11 Canadian Heart Health Initiative, 2002, p.4.
12 Ibid. p.4.
13 Ibid. p.4.
14 Ibid. p.4.
15 Ibid. p.6.
16 Ibid. p.7.
17 Ibid. p.9-10.
18 Ibid. p.10.
19 Ibid. p.17.
20 Riley, Barbara L., Sylvie Stachenko, Elinor Wilson, Dexter Harvey, Roy Cameron, Jane Farquharson, Catherine Donovan, and Gregory Taylor. 2009. “Can the Canadian Heart Health Initiative Inform the Population Health Intervention Research Initiative for Canada?” Canadian Journal of Public Health 100 (1), p. I-21.
21 Canadian Heart Health Initiative, 2002, p.40.
22 Ibid. p. 550.
23 Elliott, S.J., S.M.Taylor, R. Cameron, and R. Schabas. 1998. “Assessing Public Health Capacity to Support Community-based Heart Health Promotion: the Canadian Heart Health Initiative, Ontario Project (CHHIOP).” Health Education Research Theory and Practice 13 (4), p. 607.
24 Huxham, Chris. 2003. “Theorizing Collaboration Practice.” Public Management Review 5 (3), p. 404.
25 Sabatier, Paul A. and Hank C. Jenkins-Smith. 1999. The Advocacy Coalition Framework: An Assessment. In Theories of the Policy Process. Ed. Paul A. Sabatier. Boulder, Colorado: Westview Press, p. 122.
26 Schlager, Edella. 1995. “Policy Making and Collective Action: Defining Coalitions within the Advocacy Coalition Framework.” Policy Sciences 28, p. 264.
27 Innes, Judith E. and David E. Booker. 2003. “Collaborative Policy-making: Governance through Dialogue.” In Deliberative Policy Analysis: Understanding Governance in the Network Society. Eds. Maarten A. Hajer and Hendrick Wagenaar. Cambridge, U.K.: Cambridge University Press, p. 40; also Butterfoss, Frances Dunn, Robert M. Goodman, and Abram Wandersman, “Community Coalitions for Prevention and Health Promotion.” 1993. Health Education Research 8 (3), p. 320.
28 Sabatier and Jenkins-Smith. 1999.
29 Ottawa Charter for Health Promotion. 1986. Ottawa, Ont.: World Health Organization; Health and Welfare Canada; Canadian Public Health Association.
30 Achieving Health for All: A Framework for Health Promotion. 1986. Ottawa: Health and Welfare Canada.
31 Riley, Barbara L., S. Martin Taylor, and Susan J. Elliott. 2003. “Organizational Capacity and Implementation Change: A Comparative Case Study of Heart Health Promotion in Ontario Public Health Agencies.” Health Education Research 18 (6), p. 754.
32 Stachenko, Sylvie. 2001. “Case Study: the Canadian Heart Health Initiative.” In Evaluation in Health Promotion. Eds. Irving Rootman, Michael Goodstadt, Brian Hyndman, David V. McQueen, Louise Potvin, Jane Springett, and Erio Ziglio. Copenhagen: WHO Regional Publications, European Series, No. 92, p. 470.
33 Promoting Heart Health in Canada, 1986.
34 Canadian Heart Health Initiative,1992, p. 3.
35 Ansell and Gash, 2007, p.550.
36 Mitchell, Shannon M. and Stephen M. Shortell. 2000. “The Governance and Management of Effective Community Health Partnerships: A Typology for Research, Policy, and Practice.” The Milbank Quarterly 78 (2), pp. 241-89.
37 Mitchell, Shannon M. and Stephen M. Shortell. 2000. “The Governance and Management of Effective Community Health Partnerships: A Typology for Research, Policy, and Practice.” The Milbank Quarterly 78 (2), pp. 241-89.
38 Vangen, Siv and Chris Huxham. 2003. “Nurturing Collaborative Relations: Building Trust in Interorganizational Collaboration.” The Journal of Applied Behavioral Science 39 (1), p. 21; Ansell and Gash, 2007, p. 551.
39 Butterfoss, Frances Dunn, Robert M. Goodman, and Abraham Wanderman. 1993. “Community Coalitions for Prevention and Health Promotion.” Health Education Research 8 (3), p. 324.
40 Lasker, Roz D., Elisa S. Weiss, and Rebecca Miller. 2001. “Partnership Synergy: A Practical Framework for Studying and Strengthening the Collaborative Advantage.” The Milbank Quarterly 79 (2), p. 194.
41 Mitchell and Shortell, 2000, p.262.
42 Ibid. p. 254.
43 Imperial, Mark T. 2005. “Using Collaboration as a Governance Strategy: Lessons from Six Watershed Management Programs.” 37 (3), p. 284.
44 Johns, Carolyn M., Patricia L. O’Reilly and Gregory J. Inwood. 2006. “Intergovernmental Innovation and the Administrative State in Canada.” Governance: An International Journal of Policy, Administration, and Institutions 19 (4): 627-49.
45 Painter, Martin. 2001. “Multi-level governance and the Emergence of Collaborative Federal Institutions in Australia.” Policy and Politics 29 (2), p. 140.
46 Nelson, Lisa S. 2001. “Environmental Networks: Relying on Process or Outcome for Motivation.” In Getting Results through Collaboration. Ed. Myrna P. Mandell. Westport, Connecticut: Quorum Books, 2001, p. 93.
47 O’Toole, Lawrence J. Jr. 1997. “Treating Networks Seriously: Practical and Research-Based Agendas in Public Administration.” Public Administration Review 57 (1), p. 49.
48 Innes, Judith E. and David E. Booker. 2003. “Collaborative Policymaking: Governance through Dialogue.” In Deliberative Policy Analysis. Eds. Hajer and Wagenaar, p. 59.
49 Canadian Heart Health Initiative, 2002, p. 12.
50 Imperial, 2005, p.304.
51 Ansell and Gash, 2007, p. 550.
52 Huxham, Chris and Siv Vangen. 2000. “Leadership in the Shaping and Implementation of Collaboration Agendas: How Things Happen in a (Not Quite) Joined-Up World.” Academy of Management Journal 43 (6), p. 1170.
53 Provan, Keith G. and H. Brinton Milward. 2001. “Do Networks Really Work? A Framework for Evaluating Public-Sector Organizational Networks.” Public Management Review 61 (4), p. 420.
54 Sabatier and Jenkins-Smith. 1999, p.138.
55 Elliott et al., 1998, p. 618.
56 Butterfoss, Frances Dunn, Robert M. Goodman, and Abraham Wandersman. 1993. “Community Coalitions for Prevention and Health Promotion.” Health Education Research 8 (3): 315-30.
57 Riley, Barb and Annamaria Feltracco. 2002. Situational Analysis of the Canadian Heart Health Initiative: Final Report. Unpublished document, p.v.
58 Canadian Heart Health Initiative, 2002, p. 36.
59 Roussos et al., 2000, p. 385.
60 Khator, Renu and Nicole A. Brunson. 2001. “Creating Networks for Interorganizational Settings: A Two-Year Follow-up Study in Determinants.” In Getting Results through Collaboration. Ed. Myrna P. Mandell, p. 156. See also Kingdon, John W. 2003. Agendas, Alternatives, and Public Policies. New York:Longman.
61 Roussos, 2000, p. 385.
62 Paquet, Gilles. 2008. “Governance as Stewardship.” Optimum Online 38 (4): 1-14.
63 Huxham, Chris. 2003. “Theorizing Collaborative Thuggery.” Public Management Review 5 (3), p.417.
64 Roussos, 2000, p. 385.
65 Butterfoss, 1993, p. 322.
66 Takahashi, Lois and Gayla Smutny. 2002. “Collaborative Windows and Organizational Governance: Exploring the Formation and Demise of Social Service Partnerships.” Non Profit and Voluntary Sector Quarterly 31, p. 168.
68 Riley and Feltracco, 2002, p. 10.
69 Riley et al., 2009, p. I-24.
70 Gilles Paquet. 2009. Scheming Virtuously: The Road to Collaborative Governance. Ottawa: Invenire Books.
71 Lasker et al., 2001, p. 194.
72 The Globe and Mail, June 23, 2009, p. L4.
73 Website of Canadian Heart Health Strategy and Action Plan (http://www.chhs-scsc.ca/web/).
74 Donald Savoie. 1999. Governing from the Centre : The Concentration of Power in Canadian Politics. Toronto: University of Toronto Press.
75 Huxham, 2003, p. 414.
76 Huxham, 2003, p. 414.
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