Seena Perumal and Stacie Pallotta
Community health coalitions must be “dedicated to recognizing the autonomy of its members while promoting and maintaining a forum whereby its members can join together to collectively plan, share resources, develop strategies[, and] assist in the implementation of programs to address the health needs of all citizens in the community.”
Community Health Coalition, Cherokee County, Oklahoma, Description and Purpose Statement, October 1999. [Available Online: http://www.intellex.com/~cchd/tp/purpose.htm]
What is a Coalition?
Often used interchangeably with community organizations or neighborhood organizations, the concept of coalitions tends to be ambiguous. Early definitions of coalition, such as an “organization of organizations”15 or as a “time-limited organization in which there is a convergence of interest in the part of a number of actors... and an interaction around furthering these common interests,”14 are obviously vague. Due to the number of different definitions, one consistent meaning of coalition should be provided for the sake of clarity. Accordingly, coalition will be defined as “a temporary alliance of groups and individuals who band together to achieve both political and nonpolitical objectives.”5 In this chapter, the political and nonpolitical objectives converge to address the same issue: community health promotion.
The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”10 In order to reach this goal, the WHO recognizes several factors as essential for health. These factors include peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.17 Since these basic conditions will not be met until increased attention is given to healthcare, the WHO, in the Ottawa Charter of 1986, emphasizes the need for health promotion.17 Health promotion refers to the design and implementation of programs and processes that will enable individuals “to increase control over, and to improve, their health.”17 Guided by the three principles of enabling, mediating, and advocating, health promotion activities include:
With their strong emphasis on collective action, health promotion activities highlight the need for individuals and organizations within a community to work collaboratively as advocates and activists for health.
Advocacy or Activism: Is there a difference?
According to the Merriam-Webster On-line Collegiate Dictionary, advocacy is “the act or process of advocating or supporting a cause or proposal.”8 Activism, on the other hand, is defined as a “doctrine or practice that emphasizes direct vigorous action especially in support of or opposition to one side of a controversial issue.”8 So while activism employs direct, often confrontational actions, advocacy simply implies pleading or arguing in favor of a cause, idea, or policy. Essentially, all activism is advocacy but not all advocacy is activism.
Change can be the result of either advocacy or activism. Moreover, both spontaneous and planned actions can lead to an alteration in the status quo. It would be negligent to ignore the various contributions that spontaneous, confrontational grass-roots citizen responses to community issues have yielded.3 For the purposes of this chapter, however, only systematic and planned change through the broader area of coalition advocacy will be explored.
Purposes and Functions of a Community Health Coalition
Community health coalitions do not and need not exist for the sole purpose of achieving better health indicators in the community. Rather, their reasons for existence can be as varied as the means by which they are formed. Some coalitions are formed primarily to exchange information between various organizations1 while others focus on building relationships within the community11. Improvements in health communication and awareness are important components of creating ‘social-well-being.’ Moreover, as the case study described later will indicate, different organizations joining together (strength in numbers) with a common voice can often create ‘community power’ or a sense of empowerment. Targeting this power towards healthcare sends a clear message to outsiders that the community is concerned about the well being of its citizens.
Health care coalitions can also encompass one of several primary functions, such as service delivery, planning and policy development, surveillance and assessment, and education and outreach.7 Therefore, coalitions that do focus on improving the quality of healthcare can have varied campaigns, from the improvement of healthcare delivery through information gathering, to the lobbying of public officials for different health policies, to the actual operation of health service programs to fill existing gaps in health care.
Whatever the reason for formation, the need for community health advocacy coalitions should be apparent from preceding chapters. Without once again describing the various problems in public health, the number of uninsured Americans, the inequalities in access, and the disparities in treatment should highlight a few of the reasons why community health coalitions are so vital. After all, as aforementioned, their existence at the very least demonstrates that the community is concerned about the health of its citizens and will monitor issues impacting that health. Health care providers, health related entities, community leaders, and private citizens could all become members of the coalition and help fulfill that function.
Coalition Organization 101
The process of forming a community health advocacy coalition is hardly simple. After all, not only is every community different, but every individual situation may also differ in slight, but significant, ways. Therefore, it is difficult to have one unified umbrella theory of coalition formation. Regardless, certain processes are both common and vital in every situation. This section will describe those essential steps of forming a community health advocacy coalition. The reader should be warned however that in the real-world setting, the order of the steps may need to change or emphasis may need to be placed on different parts. Indeed, the information offered here is just one of many ways a health care coalition could be formed.
For the sake of simplicity, several assumptions have been made in the writing of this section. First, parties interested in forming a coalition have been identified or have made initial contact with each other. Second, the coalition’s focus is community health advocacy, be it creating health interventions or demanding legislative change. Third, the coalition is interested in gauging its effectiveness and success in the community. In a real-world setting, the first assumption may not always hold true. A problem or need in the community may have become apparent and one organization therefore decides to create a coalition around the issue.
Organizing a community health advocacy coalition requires that several important components be addressed. Those organizations or individuals who will be involved in planning and implementing the coalition goals need to be identified. These partnering groups must agree upon on an organizational framework best suited to the coalition’s objectives. Both the community’s needs and readiness to address those needs must be assessed. The coalition must clearly define, plan, and design their health care advocacy strategies. Lastly, the coalition must monitor the implementation of those strategies and also work to ensure its sustainability within the community.
Five-Stage Community Organizing Process for Health Promotion
Health promotion at the community level by N. Bracht(1990) serves as the primary source for all five stages described.
Figure 1 depicts the five-stage community organizing process for health promotion.
“Community organization is a planned process to activate a community to use its own social structures and any available resources (internal or external) to accomplish community goals, decided primarily by community representatives and consistent with local values. Purposive social change interventions are organized by individuals, groups, or organizations from within the community to attain and then sustain community improvements and/or new opportunities.”
Bracht, 1990, Pg. 67.
(Source: Bracht, N. (Ed.). Health Promotion at the Community Level. Newbury Park, California: Sage, 1990. Pg. 74.)
Step One. Community analysis
The central components of community analysis are “assessing community capacity to support a project, potential barriers that exist, and community readiness for involvement.”3
First, the community that the coalition will target or hopes to impact must be clearly defined. A web site sponsored by the University of Minnesota (2000) suggests three components of defining a community: space and geopolitical boundaries, networks of social relations, and systems of power and influence.13 Space and geopolitical boundaries refer to the idea that a person’s “community” may best be defined broadly, as more than cities or counties. The area in which a person lives, works, plays, shops, and socializes may hold the most merit when considering what area to serve with a coalition.13 Networks of social relations suggest the location of religious services and civic functions, for example, be considered when implementing an intervention.13 Finally, an important issue for public health planners is identifying the institutions, organizations, and leaders that if involved in a coalition will increase its chance for success.13 Overall, by considering the definition of the community, organizers of a coalition can be better prepared for obstacles they may face.
Second, data concerning the needs of the community must be collected. Need is defined as “a discrepancy or gap between ‘what is,’ or the present state of affairs in regard to the group and situation of interest, and ‘what should be,’ or a desired state of affairs.”16 A needs assessment or “a systematic set of procedures undertaken for the purpose of setting priorities and making decisions about program or organizational improvement and allocation of resources”16 utilize a variety of data collection techniques. These techniques include, but are not limited to, interviews with key community people, focus groups, public meetings or forums, and surveys. Qualitative data obtained can be analyzed by looking for common themes in responses, while numerous statistical methods can analyze the quantitative data.
Third, the community capacity, barriers, and readiness for change must be assessed.3 The resources, in terms of key organizations, individuals, and finances, need to be identified.3 In addition, community characteristics that would limit the effectiveness of the coalition must also be understood. Lastly, the coalition organizers must determine the level of interest for the coalition in the community and whether the identified needs are urgent or crucial enough to warrant a coalition effort.3 All these factors can be determined through a properly designed needs assessment. It might be useful to also examine the history of health advocacy coalitions in this community and their level of effectiveness.3
Once this information is obtained, the data must be synthesized and priorities for intervention need to be set.3 All coalition members must agree upon the chosen priorities.
Step Two. Design and Initiation
After having a basic sense of the community needs and coalition priorities, the actual core-planning group of the coalition must be established.3 Composed of a handful of interested members who are willing to make a commitment to the coalition, this group must guide the actions of the coalition until a formal leader or board is chosen.3 Hence, their main responsibilities are to assist in the processes of community analysis and priority setting. The core-planning group should also decide upon a mission statement, as well as developing some short-term and long-term goals.
After having fulfilled those responsibilities, the core-planning group should decide on a coalition coordinator and organizational structure.3 Since the coalition will quickly increase in number, adopting an official framework for operation from the very beginning is recommended. After all, power struggles and hidden agendas should be revealed during the early parts of coalition formation, not later.
A variety of organizational structures can be used in coalitions. Dluhy (1990) suggests a classic model, which emphasizes clarity of tasks and the coordination of these tasks.5 Figure 2 is an abridged version of this model. Not only can this structure be used for different types of coalitions, but as coalitions move toward permanence in organizational structure, this model continues to be accommodating.
(Source: Dluhy, MJ. Building coalitions in the human services. 1st Ed. Newbury Park (CA): Sage Publications, Inc; 1990.)
In addition to this classic model, the University of Minnesota describes two other structures and they should be considered when planning coalition framework. The first such framework is the lead agency model. This approach involves identifying an existing organization that is able to develop, coordinate, and implement the coalition goals.13 By letting the group be mainly run by a lead agency, the coalition may gain credibility (based on the previous reputation of the lead agency) and influence (based on the lead agency’s relationship with community leaders and public officials). In addition, lead agencies can often provide their own resources, in terms of volunteers, staff time, money, etc, to the coalition.13 If choosing a lead agency model, it is important to keep in mind that in the same fashion the lead agency’s reputation and connections can help, they can also hinder the coalition if those factors are poor. In addition, lead agencies may be members of multiple coalitions or be in charge of multiple projects – it is important to get a commitment of time and resources from them.13 Lastly, lead agencies may try to push their own agendas or programs unto the coalition. If the need for the lead agency’s membership and resources is strong, then the coalition may be susceptible to this pressure.
The second framework is the advisory group model. This approach involves forming an advisory board composed of important community groups.13 Similar to the lead agency model, if the members of the advisory board are well connected, some of that credibility and influence may extend over to the coalition. Unlike the lead agency model though, this framework offers much more flexibility; board members can be rotated on a periodic basis so that all coalition members feel as if they are equal partners.13 Even with these strengths, the advisory group model too has its share of potential weaknesses. Power struggles may emerge within the board members and certain groups may be devoting more time and resources than others. Secondly, key community leaders may not wish to join the organization because they desire more power than offered by an advisory board model.13
Ultimately, the degree to which a model works for a given coalition is dependent on the coalition leaders, the issue at hand, and the community itself. Therefore, the type of organizational framework one chooses must be appropriate to “the conditions of leadership, influence, and decision-making” in a given community.13
After an organizational structure is selected, additional coalition members should be identified and recruited.3 The membership of the coalition should reflect the major organizations and groups in the community.3 It is recommended to contact organizations or groups that can offer technical expertise/capacity, are regarded in the community with credibility, and have an agency culture of partnership and collaboration. In addition, when the community group becomes a coalition member, the organizer must ensure that the organization representative has the authority to speak for his or her group.3 The new members must agree to the mission statement and goals.
Once these new members are added to the coalition, training and education should be provided to them.3 “Training helps members increase confidence about their abilities and contributions to community projects and builds understanding of the extent of the health problem being addressed, the consequences of that problem, and alternative solutions.”3
Lastly, the roles and responsibilities of coalition partners, staff, volunteers, and even the board itself should be clearly defined.3 These job descriptions may prevent against any future misunderstandings or power struggles.
Step Three. Implementation
The combination of the first two steps, community analysis and design-initiation, lays the groundwork for developing a step-by-step work-plan.3 The community analysis provided information about the pressing needs of the community and the areas that deserved priority. That data was then utilized in the design-initiation stage to form a mission statement and coalition goals. The implementation stage requires that those abstract goals be translated into clearly defined points of action.3 The strategies developed should not be “one-shot” deals,3 or actions without reflection. After all, few public health problems are solved with short-term intervention. Effective coalition work requires multiple programs that are woven in a thorough and integrated manner.3
In addition, even though formal members for the coalition have already been recruited, it is advisable to continue generating citizen support.3 Community members should be encouraged to volunteer or participate in coalition activities.
Step Four. Maintenance and Consolidation
Such encouragement will help ensure the sustainability of the coalition in the long run. Bracht outlines three primary ways of strengthening coalition work: “integrate intervention activities into community networks; establish a positive organizational culture; and establish an ongoing recruitment plan.”3 Coalitions, unlike most social agencies and business firms, must continue to strive for clarity and purpose as well as reassure their members that their participation is having practical, tangible, and positive impacts on their community.5
Step Five. Dissemination and Reassessment
As the coalition’s work progresses, it is useful to conduct a new community analysis and check for any differences in needs, resources, etc.3 In addition, updating the community analysis may help identify additional members for the coalition, who are either new to the community or were previously not interested.3
Secondly, the effectiveness of coalition programs should be assessed.3 Victory is not the only possible outcome measure of value here. The coalition can also analyze whether the number of participants increased at events, whether the coalition membership grew, whether there is an increased awareness on healthcare issues, etc.3 These results should be summarized and made available to the community.3 The University of Minnesota suggests two possible ways of ‘getting the word out.’ First, an annual campaign emphasizing the goals and accomplishments of the coalition thus far can be an effective way to remind the community of the coalition.13 This is especially beneficial when a coalition has made great progress in an immediate response to a problem, but would like the community to recognize its commitment to long-term improvement as well. Secondly, the University of Minnesota (2000) suggests coalition leaders simply “spread the message.”13 Engaging the media and encouraging coalition members to grant interviews helps alert the public to the coalition.
Lastly, the coalition should determine modifications to existing strategies and future directions.3 It is important to constantly examine the mission statement and current programs to make sure the two are in line.
In the end, no matter how strong a coalition or how vital a need, the lack of funding could spell disaster. Fundraising is an inevitability of coalition work, unless a member organization donates the necessary resources as an in-kind contribution. If no such generous organization pulls through, then it is recommended that the coalition organizer take a crash course in grant writing. Grants are often the way many coalitions receive funding. Coalitions can also charge organizations for membership, but that might potentially dissuade certain groups from joining. In addition, coalition can organize various fundraising events, such as dinners, auctions, etc.
The finer details of fundraising and grant writing are outside the scope of this chapter.
Advantages and Disadvantages of a Coalition
Researchers over the years have noted various strengths and weaknesses of having a coalition. Therefore, before implementing a coalition of any type, it would be advantageous to carefully consider these factors.
Criticisms of coalitions often begin with the idea that small-targeted groups with narrow objectives can garner change in certain circumstances.9 Indeed, they can be quite effective and if and when successful, do not need to share the payoffs with any other groups.5 Moreover, coalitions can divert energy and resources from an organization.5 They also may take positions contrary to or unsupportive of an individual organization’s interests or policies. In addition, coalitions may use a “slow, consensus-building process for decision making resulting in a weakened position on some issues.”5 After all, the differences among the organizations that comprise the coalition may prevent it from taking strong stands on particular matters or moving as quickly as desired.2
These disadvantages though should not negate the desirability of joint action by groups under certain conditions. Indeed, in situations where an individual organization is powerless to effectuate change, coalitions may be better equipped to successfully resolve the issue. Thus, an individual or organization needs to find the proper balance between working alone and collaborating with other groups. Moreover, coalitions allow individual members to become involved in new and broader issues without concerns of total development or management.5 Ultimately, coalitions provide its members with a greater number of resources and a wider variety of strategies from which to tackle an issue.
Founded in 1987, Jobs with Justice (JwJ) is a nationwide organization committed to improving and protecting workers’ rights.6 At the heart of JwJ’s philosophy is the belief that success can only be attained when the struggle for workers’ rights is a part of larger campaigns for social and economic justice.6 With that end in mind, JwJ has created a network of local coalitions “in over 40 cities in 29 states in all regions of the country.”6 These local coalitions are comprised of labor unions, faith-based, community, and student organizations. Ultimately, JwJ hopes that “by creating strategic alliances locally and among organizations nationally and developing a broad base of support, Jobs with Justice coalitions are re-building the infrastructure that gives communities a sense of their own power.”6
The Jobs with Justice coalition in Cleveland, Ohio was formed in 1992 and has almost 60 member organizations that cover the full range aforementioned. In 2001, during Cleveland JwJ’s first annual strategic planning retreat, the member organizations decided that they wanted a specific sub-committee, termed “working group,” to address healthcare issues. While JwJ was already active in a number of healthcare campaigns, the coalition felt problems in the field were significant enough to warrant a separate effort. Indeed, at that time (and still today), the healthcare indicators of Ohio were both dismal and staggering in their magnitude. In 1998, eleven percent of Ohioans were uninsured and over four hundred thousand Ohioans lost health coverage that year.12 In addition, the number of Ohioans without prescription drug coverage was estimated to be 2.2 million.12 With these numbers in mind, the JwJ coalition approved the formation of a HealthCare Working Group.
The membership of the Healthcare Working Group reflects the diversity and community relationship-building that is at the core of Jobs with Justice. Athena Godet-Calogeras, Associate Director of Universal Health Care Action Network of Ohio (UHCAN Ohio), serves as chair of the group. While her professional role gives her health expertise, many of the other members of the group have never been involved in health care issues before. These members represent various community and faith-based organizations in Cleveland, as well as a number of labor unions. It is their common conviction to protect the rights of working class people, whether that involves advocating for a living wage law or health care, that binds them together.
The mission or strategy of the Healthcare Working is: 1) To educate JwJ membership on health care issues; and 2) To work on issues related to the need for and/or achievement of universal health care. The group wants to get involved in statewide legislation that affects working people and in the local struggles of JwJ member organizations — and the community at large — where health care is an issue.
With those goals in mind, the Healthcare Working Group advocated for statewide Medicaid expansion to working parents in 2002-2001 and affordable prescription drugs for Ohioans through the Prescription Drug Fair Pricing Act in 2001-2002. These issues required the group to get involved in various letter-writing campaigns to legislators, public rallies and demonstrations, meetings with public officials, and petition drives. The group has also engaged in numerous activities supporting St. Michael Hospital and the MetroHealth Clinics.
Obviously, the Healthcare Working Group has not (yet) managed to guarantee universal healthcare for all Americans but it has won small, but significant, steps. Many local politicians now know of the group, the media (both television and newspaper) have covered all of their public events, and the members of Jobs with Justice themselves feel better aware of healthcare issues. These successes led the Cleveland Jobs with Justice coalition in its second annual strategic retreat to once again approve having a Healthcare Working Group.
1. What are some of the strengths of the Healthcare Working Group?
2. What are some of the weaknesses of the Healthcare Working Group?
3. How can the Healthcare Working Group improve its effectiveness as a coalition?
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2 Black, T. Coalition building: some suggestions. Child Welfare 1983; 62(3): 263-8.
3 Bracht, N. Health promotion at the community level. Newbury Park (CA): Sage Publications Inc.; 1990.
4 Community Health Coalition, Cherokee County, Oklahoma, Description and Purpose Statement. October 1999. [Available Online: http://www.intellex.com/~cchd/tp/purpose.htm]
5 Dluhy, M.J. Building coalitions in the human services. 1st Ed. Newbury Park (CA): Sage Publications, Inc; 1990.
6 Jobs With Justice. About JwJ. 2002. [Available Online: http://www.jwj.org/]
7 Mays, G.P., Halverson, P.K., and Kaluzny A.D. Collaboration to improve community health: trends and alternative models. Joint Commission J Qual Improv 1998; 24(10): 518-40.
8 Merriam-Webster Online: The Language Center. http://www.merriam-webster.com/. Collegiate Dictionary: 2001.
9 Olsen, M. The logic of collective action: public goods and the theory of groups. New York (NY): Schocken; 1968.
10 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
11 Rothman, J. Approaches to community intervention. In Rothman J, Erlich J, Tropman J (eds.), Strategies of community intervention. 5th Ed. Itasca (IL): FE Peacock 1995.
12 Universal Health Care Action Network of Ohio. About UHCAN Ohio. 2002. [Available Online: http://www.uhcanohio.org]
13 University Of Minnesota, School of Public Health, Division of Epidemiology. REACT web site: community organization. April 2000. [Available Online: http://www.epi.umn.edu/REACT/]
14 Warren, M. Social change and human purpose. Chicago (IL): Rand McNally; 1977.
15 Wilson, J. Political organizations. 1st Ed. New York (NY): Basic Books; 1973.
16 Witkin, B.R. and Altschuld, J.W. Planning and Conducting Needs Assessments: A Practical Guide. Thousand Oaks, California: Sage, 1995.
17 World Health Organization. Ottawa charter for health promotion. First International Conference on Health Promotion. Ottawa: November 21, 1986. [Available Online: http://www.who.int/hpr/archive/docs/ottawa.html]