4 The Global Programme on Health Promotion Effectiveness

4

The Global Programme

on Health Promotion Effectiveness

A Case Study of Global Partnership Functioning

J. H OPE C ORBIN AND M AURICE B. M ITTELMARK

Introduction

Building the case for effectiveness in health promotion cannot end with creating evidence, but must extend to assembling and disseminating the evidence in ways that communicate convincingly with people in positions to make a difference. In health promotion, there has been lively debate about the best methodology for these activities.

Some feel the traditional academic approach is best, in which scholars examine findings from empirical studies and publish reviews in peer-reviewed academic journals. Critics point out that this approach has limits, both in the selection of evi- dence and in the audience reached. Effective health promotion that is unpublished, or published in languages other than English, is usually omitted. Further, the results presented in these reviews have mostly to do with health effects and fail to explore political, social or economic implications of the science. Perhaps most limiting, the dissemination of such reviews hardly ever reaches beyond the schol- arly community. There is no dependable mechanism to bring academia to policy makers. However, some scientists are effective lobbyists, showing that better con- nection between science and policy can result when scientists break with their tra- ditional ways of assembling and communicating knowledge.

Academics working in the disciplines that feed health promotion have been increasingly concerned with these issues. If inappropriate methods produce weak findings, making the case for effective health promotion is a hopeless cause. This situation has prompted the emergence of alternative frameworks for evaluating and communicating health promotion’s effectiveness, of which the Global Programme for Health Promotion Effectiveness (GPHPE) is an exemplar. As the first global partnership for health promotion effectiveness, the GPHPE has lessons to offer regarding what makes such a partnership function well, and what inhibits good functioning. This chapter’s purpose is to examine the GPHPE, summarizing key results from a 2006 study of its work processes and functioning (Corbin, 2006). In turning the light of inspection inwards, to examine the GPHPE’s functioning, our aim is to suggest ways in which the GPHPE and large-scale partnerships in health promotion in general, can be organized and managed for optimal functioning.

41

Specifically, the study used a systems theory framework – inputs, through- puts and outputs – to examine the GPHPE as a new way of addressing the effectiveness issue (Wandersman, Goodman & Butterfoss, 1997). How does a partnership model work when the aim is to review evidence of effectiveness and disseminate the results to decision-makers? What do the partners bring to the work, and what do they get back? In what ways does partnership create synergy? What aspects of a partnership have the potential to impede its func- tioning? Exploration of these questions can provide a basis for improvements in the GPHPE itself, but may also suggest guidelines for partnership develop- ment and management for other types of health promotion partnerships. This is highly relevant, because the field of health promotion places great value on the partnership model of collaboration, yet little research is available about how health promotion partnerships function.

The Global Programme for Health Promotion Effectiveness

The GPHPE is a worldwide partnership looking at health promotion effectiveness around the globe. The multi-partner initiative is coordinated by the International Union for Health Promotion and Education (IUHPE) in collaboration with the World Health Organization (WHO) and partners from national agencies and organizations in Kenya, Switzerland, England, The Netherlands, Canada, the United States and India, among others (GPHPE, 2005).

The main aim of the GPHPE is to “raise the standards of health promoting pol- icy making and practice world-wide by: reviewing and building evidence in terms of health, social, economic and political impact; translating evidence to policy makers, teachers, practitioners, researchers; and stimulating debate on the nature of effectiveness” (GPHPE, 2005).

History

The GPHPE grew out of a similar initiative in Europe. In 1999, the IUHPE pub- lished the culmination of an evidence-gathering project funded by the European Commission and the US Center for Disease Control, in a set of books called The Evidence of Health Promotion Effectiveness. This project gathered the expertise of the IUHPE professional network, politicians, and media and communications spe- cialists to review the evidence for health promotion effectiveness with a special focus on practical outcomes. As recommended by the partnering policy makers, the books examine not only the health impacts of health promotion but also the economic, social and political impacts as well. The balance of scholarly evidence and practical utility of the books has made them “the most sought after references in the field (GPHPE, 2002, p. 1).”

*

The complete list of partners is available in the Annex of this volume.

The popularity of the books, and the appeal of the methodology that spawned them, spread quickly beyond Europe, and many experts suggested that similar efforts in other parts of the world were needed. The IUHPE decided that, not only was there a need to contribute more evidence to the knowledge base, but that the bias excluding evidence in languages other than English also needed to be addressed and rectified. The GPHPE was initiated to address these issues. The planning began shortly after the publication of the books in 1999 and the first Global Steering Group meeting was held in Amsterdam in 2001 (GPHPE, 2002).

Originally, the plan for the GPHPE was for partners in the IUHPE’s regional divisions around the world to move forward in parallel using the European work as a blueprint for their work. Initial assessments illuminated significant variations in health promotion’s research capacities and accomplishments, both between and within the regions. Therefore, the GPHPE decided collectively to encourage the regions to undertake the effectiveness review and dissemination work at a pace and in a manner suited to the particular conditions and contexts of each region (GPHPE, 2004b).

Structure

The work of the GPHPE is conducted in seven regions: Africa, Europe, Latin America, North American, Northwest Asia, Southeast Asia and the Southwest Pacific. Each of these regions has a regional leader or in some cases, co-leaders and some regions also have a regional coordinator. At the global level, there is a global leader and a global coordinator. The work of the GPHPE is overseen by the Global Steering Group (GSG). The GSG is comprised of representatives from each regional program, donor organizations, some technical advisors and the global leader and coordinator. The GSG is the main decision making body of the global partnership (GPHPE, 2004a). So, the GPHPE is actually a global partner- ship comprised of multiple regional partnerships. The present study did not delve into the functioning of regional partnerships but focused on global functioning.

Products

One of the first tasks undertaken by the GPHPE was translating the original European Effectiveness books from English into other languages, including as of this writing French, Spanish, Russian, Chinese, Mongolian, Japanese and Korean.

In 2004, a special supplemental issue of the IUHPE journal, Promotion &

Education, was dedicated to a summary of the proceedings of a one-day sym-

posium held in Paris on the international debate on the effectiveness of health

promotion. The event was arranged to raise awareness and provide a forum for

exchange on the highly debated concepts of evaluation, evidence, effectiveness

and how they relate to policy. This special issue was then launched at another

conference concerned with these topics, held in Quebec in October 2004

(GPHPE, 2004b).

Also in 2004, members of the GPHPE organized and arranged a track on effec- tiveness at the 18th World Conference on Health Promotion and Health Education held in Melbourne, Australia. At the conference, the GPHPE was presented in “its integral entirety.” A symposium offered an overview of GPHPE activities, and a number of regional symposia were held as well (GPHPE, 2004b).

In 2005, another special issue of Promotion & Education was published on the theme of effectiveness in mental health promotion. The monograph in which this chapter appears is the latest GPHPE product, and together with the other products illustrates how the partnership has utilized IUHPE communication channels for the dissemination aspects of the project.

Funding

The GPHPE is an ongoing programme of the IUHPE. Rather than operating like a project with specific funding for specific products, it is a continuous effort sup- ported largely by voluntary efforts of IUHPE members. At times, certain regions have received funding from GPHPE partners while others have never received such support. Thus, distribution of the few financial resources available is uneven.

Partnership Research in the GPHPE

Here, selected findings from the 2006 study of the GPHPE are summarized, and some implications for global partnership for health promotion are considered. The analysis used a systems theory framework, as mentioned above, and the results are summarized using the systems elements inputs, throughputs and outputs.

Partnership Inputs

Three types of inputs were identified from the data, including one type of input whose significance might have been overlooked in a casual analysis. Partner resources (peo- ples’ time and effort) and financial resources were expectedly referred to in many ways by the study respondents. In addition, the raison d’etre of the GPHPE’s estab- lishment, to raise the standards of health promoting policymaking and practice, lent an air of urgency to the enterprise that motivated partners to join and that helped to attract financial support. The three inputs – partners, finance and the problem – interacted in positive ways. The problem stimulated motivation to join, the partners mobilized financial resources, and these in turn enabled the partners to conduct work (e.g., meetings, publications) that would otherwise not have happened.

Throughputs: Partnership Processes

The throughput portion of the partnership system refers to partnership processes.

Throughput can be enhanced and reinforced by positive cycles of interaction, or

can be impeded and diminished by negative cycles of interaction. Here, both types of cycles are illustrated using examples having to do with GPHPE leader- ship and communication practices.

Leadership

Cycles of positive interaction were enabled by skilled leadership, which in the GPHPE created a positive partnership context. Data from the study revealed that leadership:

• fostered positive interaction,

• inspired confidence,

• focused partners on the tasks at hand,

• promoted a climate of openness, trust, autonomy and patience,

• resolved conflict, and

• modelled pragmatism.

At the same time, the study of the GPHPE revealed that leaders need to be alert to, and prevent if they can, partnership problems that can arise despite the best of intentions. In a complex globe-spanning partnership, the potential for inevitable misunderstandings to blossom into diminished trust, conflict, and dominance problems should be anticipated. Lowered trust can inhibit the partnership’s ability to function by acting as a dividing force, fostering suspicion among some partners and draining motivation to invest in the partnership. Left unchecked, negative cycles may result in some partners withdrawing, others coming to dominate, and others feeling unappreciated. Managing negative tendencies is a particular chal- lenge in a global partnership because people are dispersed and face-to-face contact is rare, and also because cultural and language differences add to the communica- tion challenge.

Communication

Positive processes for communication include purposeful, frequent, and recognis- able information exchanges. In the GPHPE, no mechanism for communication was more positive than occasional face-to-face meetings. Face-to-face meetings allow for immediate, unfettered exchange that is conducive to the production of synergy. This immediate interaction also facilitates joint decision-making and goal-setting. Face-to-face meetings also allow new partners to integrate into the ongoing dynamic of the partnership and feel included. This lesson from the GPHPE has important implications in the era of the Internet, in which email and teleconferencing are looked to as cost saving communications technology. It seems that the successful use of distance communications depends on interper- sonal ties forged by periodic direct contact, and operating budgets need to be planned with this in mind.

On the other side of the coin, poor communication can negatively impact

partnership functioning by leaving people feeling overwhelmed, or left out

and confused. Poor communication can exacerbate problems of accountabil- ity, and can reduce a partnership’s capacity for exchange and synergy. If mechanisms for efficient and dependable communication are not firmly in place, partners’ perceptions of the collaboration can deteriorate and a cli- mate of discouragement can take hold. Good communication ensures maxi- mum transparency, important because without transparency, trust suffers.

With too little information, partners can become discouraged. With too much information, people may feel guilty about not being able to keep up.

Inadequate communication may lead to missed opportunities for collabora- tion by not keeping the partnership in the forefront of people’s minds and by not creating forums for sharing.

Output

Three types of partnership output were identified in the case data of the GPHPE.

These outputs were additive outcomes, synergistic outcomes and antagonistic outcomes.

Additive outcomes are outcomes that have not been affected by the interac- tion of the partnership. The mathematical description of this relationship would be 2 ⫹ 2 ⫽ 4. The inputs bypass the throughput portion of the partnership and therefore the output remains unchanged. The partners produce what they would have produced on their own. The absence of partnership interaction leaves the partnership also unchanged by these outcomes.

Synergy is the integration of inputs in interaction that produces outcomes that could not have been produced by those inputs in isolation. Mathematically this would be represented as 2 ⫹ 2 ⫽ 5. Synergy is produced through the func- tioning of the partnership. Examples of synergy provided from the case data suggest that positive interaction enhances the partnership’s ability to pro- duce synergistic results. The data also suggest that the creation of synergy, or partnership success, feeds back in to the partnership positively effecting func- tioning and thus enhancing the ability of the partnership to attract more part- ner input and financial resources. Synergistic outcomes may also have the potential to affect the partnership problem although that was not observed in this case.

Antagonistic outcomes occur when the partnership interaction has an overly taxing effect. Antagonistic output is actually less than what the inputs would have produced without the partnership process. Mathematically, antagony would be expressed as 2 ⫹ 2 ⫽ 3. That is, through the partnership process something was lost. For example, partnership processes that waste partner time or financial resources by definition produce antagony. In the worst case, 2 ⫹ 2 ⫽ 0, the case of a partnership that dissolves before meeting its aims. The data of the present case suggest that antagonistic output often appears to be no output at all.

This wasting time and money can negatively affect functioning by contributing

to cycles of negative interaction and by leading to withdrawal of partner and

financial resources.

Summary

Here, we return to the questions asked in the introduction. How does a partner- ship model work, when the aim is to review evidence of effectiveness and dissem- inate the results to decision-makers? What do the partners bring to the work, and what do they get back? In what ways does partnership create synergy? What aspects of a partnership have the potential to impede its functioning?

The first point to be made is that the full potential to study the GPHPE as a model of partnership for reviewing and disseminating evidence will be realized in the future. The GPHPE is an ongoing process, not a time-defined project, so les- sons from its functioning will emerge continuously. However, there are already some indications that the GPHPE is a workable model for managing and dissem- inating evidence of health promotion effectiveness. Most importantly, the GPHPE has published evidence summaries that incorporate evidence from cultures and arenas that would have been overlooked by traditional review approaches.

The results show that the GPHPE functions well in many ways. There are many committed partners willing to devote their time to the programme. The problem uniting these people is sufficiently urgent that it is able to inspire and motivate participation and production. While the data point out some instances of poor communication, distrust and unresolved conflict, overwhelmingly, the overall impression reported by GPHPE participants is of strong leadership and good communication.

The greatest obstacle for working in partnership as identified in the results of the GPHPE case study is a lack of financial resources. The GPHPE relies almost entirely on its volunteer base. Unfortunately, it can be quite difficult to hold volun- teers strictly accountable to meet obligations and deadlines. Financial resources actually provide two mechanisms that address this issue. Financial resources often come with external accountability measures that can help ensure that promises are kept, and kept on time. Financial resources can also help facilitate travel for face- to-face meetings. As described earlier, this type of communication greatly improves relationships and exchange, thus increasing the likelihood of producing synergy.

The ultimate test of the partnership model for managing and disseminating evi- dence of health promotion’s effectiveness, as represented by the GPHPE, will be its impact on policy-makers. That assessment is a task for the future, but the interim analysis summarized in this chapter shows that the GPHPE is functioning largely as planned, it is producing evidence reviews that include a widened range of evidence, and it is of sustained importance to its partners. It seems, therefore, that the conditions are in place needed to make the GPHPE a fair test of a new way of working in the evidence and effectiveness arena.

References

Corbin, J.H. (2006). Interactive Processes in Global Partnership: A Case Study of the

Global Programme for Health Promotion Effectiveness. IUHPE Research Report

Series. 1 (1), 1–70.

GPHPE. (2002). Brief Presentation of the Global Programme on Health Promotion Effectiveness: Global Programme on Health Promotion Effectiveness.

GPHPE. (2004a). Brief Presentation of the Global Programme on Health Promotion Effectiveness: Global Programme on Health Promotion Effectiveness.

GPHPE. (2004b). The Global Programme on Health Promotion Effectiveness. Promotion and Education, XI (3), 167–168.

GPHPE. (2005). The Global Programme on Health Promotion Effectiveness Leaflet (pp. 167–168): Global Programme on Health Promotion Effectiveness.

Wandersman, A., Goodman, R.M. & Butterfoss, F. (1997). Understanding Coalitions and

How They Operate: An “Open Systems” Organizational Framework. In: M. Minkler

(ed), Community Organizing and Community Building for Health (pp. 261–277). New

Brunswick, N.J.: Rutgers University Press.