With the nation now in the fight against the COVID-19 pandemic, the health care, public health, and social services sectors are rapidly adapting to new ways of working together as resources are stretched and both workers and the public are more socially distant from one another. The coronavirus creates a new sense of urgency for how we design interactions among the three systems. Efforts to collaborate in new ways have generally been supported by one-off opportunities, whether positive or negative. Onetime grant funding and pilot policies are examples of positive opportunities. Hurricane Katrina and the COVID-19 pandemic are examples of negative opportunities.
Based on their learning from years of their own grant making and that of others, the Robert Wood Johnson Foundation (RWJF) supports and learns from work that seeks to better align health care, public health, and social services. They envision alignment among systems that goes beyond onetime efforts, that better values the unique contributions of each sector, and that gives power and voice to community members. We describe a cross-sector alignment theory of change that aligns with the foundation’s vision of a culture of health that provides everyone in the United States a fair and just opportunity for health and well-being.1
The Georgia Health Policy Center coordinates the national initiative Aligning Systems for Health: Health Care + Public Health + Social Services in partnership with RWJF. It focuses on learning about effective ways to align health care, public health, and social services to better address the goals and needs of the people and communities they serve.2 Aligning Systems for Health is testing a cross-sector alignment theory of change (Figure 1) that was created by RWJF from years of their own, and others’, supported research and learning. The Georgia Health Policy Center, in its initial work, has adapted definitions of the three sectors from RWJF’s complementary research program, Systems for Action.3 To sustain impact, cross-sector collaboratives should consider activating four core components of cross-sector alignment: Purpose: The focus of the cross-sector effort, informed by and supportive of community voice Data: Shared data that is meaningful to all partners and that enables sectors to effectively coordinate activities and measure shared progress Financing: Long-term financing that supports partnerships with incentives and accountability Governance: Robust governance structures that include local representation and voice
Purpose: The focus of the cross-sector effort, informed by and supportive of community voice
Data: Shared data that is meaningful to all partners and that enables sectors to effectively coordinate activities and measure shared progress
Financing: Long-term financing that supports partnerships with incentives and accountability
Governance: Robust governance structures that include local representation and voice
Each of these core components may operate at the individual, organizational, or system level and should be driven by the voice and participation of community members. The impetus to align systems is shaped by external factors that might be considered drivers of cross-sector alignment: crises such as the COVID-19 pandemic; policy, statutory, and regulatory changes such as the movement toward value-based payment; state or federal grant initiatives; and public–private partnerships; among others.
The core components are further affected by internal factors that shape organizational and system readiness, including backbone capabilities, financial management capabilities, leadership, a workforce with appropriate skills, and an information infrastructure. Cross-sector alignment is moderated by factors such as individual and organizational trust, the ability and degree to which communities are engaged, the ability to hold each other accountable for community members’ goals and needs, and the availability of evidence to implement change.
As we build our understanding of cross-sector alignment, we have surfaced a number of observations about the theory of change from what is known about collaboration. Many (but not all) of the suggested elements require sometimes extensive resources. This means that, in situations involving scarcity, less sophisticated alignment may be optimal. This does not mean that interested parties should avoid aligning. Rather, it suggests that cross-sector alignment may involve tough decisions and the establishment of priorities that will be optimal only in certain contexts. The complexity and potential for variation in collaborations and collaborative context suggest that cross-sector alignment will emerge in different ways and face different challenges. It may make sense to try to formally and explicitly make sense of these different paths so that individuals and organizations wishing to align are aware of potential entry points and have tools for identifying and addressing the most relevant challenges and opportunities.
The core components of cross-sector alignment overlap. In other words, they reinforce each other in a number of ways, both in real time and over time. Accordingly, they could be understood not only linearly but also cyclically. A shared purpose is not necessarily a primary purpose. There are many reasons to join health-oriented collaboratives, and each partner comes with a different set of priorities. While establishing shared purpose may be an important process, it may also be important to develop a means of managing the distinct and divergent priorities of the partners involved. Equity, a key component of cross-sector alignment outcomes, is closely linked to community voice. However, we have not yet fully elaborated best practices for prioritizing community voice.
RWJF and others have supported cross-sector alignment for several years, and its impact is beginning to be realized. The Accountable Health Communities Model, supported by the Centers for Medicare & Medicaid Services, was launched to address the critical gap between clinical care and community services in the current health care delivery system. Early work has developed standardized screening for health-related social needs in clinical settings (https://bit.ly/2AHjZje). Washington State launched nine accountable communities of health that are supporting the Delivery System Reform Incentive Payment program’s goals to build health system capacity and integrate physical and behavioral health services (https://bit.ly/3dyNJgF). Through a braided funding model, the State of Rhode Island directed more than $10.4 million in public health funding to community-led health equity zones to address the social determinants of health to eliminate health disparities.4 Public and private partners are supporting the California Accountable Communities for Health Initiative to realize a more forward-looking approach to building a healthier California; this initiative is creating new ways to sustainably finance cross-sector work.5
The cross-sector alignment theory of change builds on previous public health and social change models and focuses specifically on how health care, public health, and social services can better meet the goals and needs of the people and communities they serve in a way that is built to last. Like the spectrum of prevention model, the theory includes the roles of providers, coalitions, and networks; internal factors such as organizational practices; and external factors such as the roles of policy and legislation.6 Similar to the collective impact model, the theory highlights the role of purpose (common agenda) and shared data and measurement.7 The cross-sector alignment theory of change adds to these models by focusing on the well-being of individuals and communities and the roles of individual and community voices in determining desired outcomes. It challenges us to think beyond onetime, limited term efforts.
The cross-sector alignment theory of change will continue to evolve as more evidence emerges from research and evaluation on aligning health care, public health, and social services. Creating sustainable cross-sector alignment may take generations, although the COVID-19 pandemic presents an unprecedented opportunity to rethink the future. The cross-sector alignment theory of change is one tool that can help guide the work of individuals, organizations, and systems to redesign that future.
See also Dasgupta, p.
This work was supported by the Robert Wood Johnson Foundation (grant 76315).
Note. The views presented here are those of the authors and should not be attributed to the Robert Wood Johnson Foundation.
CONFLICTS OF INTEREST
None of the authors has a conflict of interest to disclose.