Systems-Level Impact: Using the Collective Impact Framework for Public Health Systems Building

By Erin Bonzon, MSPH/MSW
Associate Director, Women’s & Infant Health, AMCHP

Tegan Callahan, MPH
Program Manager, Women’s & Infant Health, AMCHP

Systems-wide progress requires decisions and actions that develop strong partnerships. Partnerships will be at the core of any comprehensive initiative. Yet, partnerships for improving maternal and child health outcomes need to go beyond traditional collaborations and public-private partnerships in order to develop collective impact and influence systems change. The concept of ‘collective impact’ was introduced in a 2011 article in the Stanford Social Innovation Review (Collective Impact, Kania and Kramer). Collective impact is a structured approach to creating collaborative partnerships with a specific focus on working together to solve complex social and health problems that do not have a single, defined source or solution. Collective impact proposes bringing together people and organizations from across multiple sectors (economic, education, health, housing, environment, business, law enforcement, etc.) to accomplish a shared set of goals.

In order to make progress on improving systems, public health partnerships should embody a ‘collective impact’ approach to improving social outcomes. Collective impact is the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem. Social innovation researchers found that successful collective impact initiatives have five core characteristics:

  • Common Agenda – a shared vision for change that includes a common understanding of the problem and a joint approach (i.e., agreed on actions) to solving the problem. In order to reach a common agenda, disagreements and differences in the definition of ‘the problem’ or ‘the goal’ must be addressed.
  • Shared Measurement Systems – agreed on ways in which success will be measured and reported are aligned and all participating organizations can hold each other accountable and evaluate successes and failures along the way.
  • Mutually Reinforcing Activities – the efforts of each stakeholder must fit into an overarching plan of action. Collective impact does not require all stakeholders to do the same thing, rather, each stakeholder should undertake a specific set of activities in which they are apt to excel, which is coordinated with the actions of others.
  • Continuous Communication – a shared vocabulary and, eventually, trust will develop through regular meetings. Stakeholders need to have constant contact with one another in order to recognize and appreciate common motivations, see their own interests will be treated fairly, and believe that collective decisions will be made based on the best possible solution to the problem.
  • Backbone Support Organizations – collaboration requires a support infrastructure. The most effective examples of collective impact have staff dedicated to the planning, management and support of the initiative. Staffing requirements for large collective impact initiatives may be as simple as: project manager, data manager and meeting facilitator.

AMCHP is currently using collective impact as a framework to guide initiatives and promote partnerships at the state and national level. Three current AMCHP initiatives that highlight the principles of collective impact and promote a collective impact approach include the Best Babies Zone (BBZ) partnership, the Adolescent Systems Capacity Tool and our new ALC phase for our ongoing project to help state MCH programs Optimize Health Care Reform to Improve Birth Outcomes.

The BBZ is a multisector approach to reducing infant mortality and racial disparities in birth outcomes and improving birth and health outcomes by mobilizing communities to address the social determinants that affect health. The BBZ approach is focused on non-traditional partners (i.e. public health, economic development, community development and education agencies) aligning under a common agenda. The development of a clear and transparent action plan is an important step in implementing BBZ, as well as central to developing a common agenda under a collective impact framework. The BBZ action plan will include a clear model of the overarching initiative framework, and a clear path toward implementing the community assessment and site partnership development and coordination. Also central to the BBZ common agenda are shared evaluation measures, currently under development, that will align the efforts within project sites as the initiative moves forward.

Other aspects of collective impact highlighted by the BBZ include continuous communication and backbone support. Communication and trust are key features of the BBZ initiative; project sites are encouraged to set-up regular collaborative meetings with their partners and the overall project will support sites in their efforts to coordinate and facilitate these collective relationships. Finally, the project provides backbone agency support on two levels. Locally, community efforts are supported through an identified backbone agency at within each of the four BBZ pilot communities. In addition, a National Leadership Team provides overall project coordination and backbone support through identifying strategies and providing technical assistance to develop cross-sectoral partnerships and coordinate the collective processes for the BBZ Initiative.

The Adolescent Systems Capacity Tool was developed in 2005 as a resource to help state maternal and child health programs assess six key areas of organizational capacity related to adolescent health: commitment to adolescent health; partnerships for adolescent health; program planning and evaluation; surveillance and data systems; education and technical assistance; and policy and advocacy. The ultimate goal of the assessment is to identify areas for organizational improvement and implement strategies to address them. In 2011, recognizing the critical role that local public health plays in improving health outcomes, AMCHP initiated a project with NACCHO to revise the SCAT to help local public health practitioners assess their organizational capacity to support adolescent health. AMCHP and NACCHO are using collective impact as the framework for the efforts. A collective impact approach was a natural fit for guiding the redesign of the ASC tool because the five conditions that are critical for collective impact to work are very similar to what the ASC tool is designed to do: provide a structured process that leads to a common agenda (development of quality improvement plans), shared measurement, continuous communication, and mutually reinforcing activities among all participants to improve adolescent health outcomes. (To learn more, see the article on page 5.)

Lastly, the new cohort of state teams for the AMCHP Optimizing Health Care Reform to Improve Birth Outcomes project ALC will be provided with direct technical assistance and training on collective impact approaches for state-level initiatives to improve birth outcomes. AMCHP recently redesigned the ALC component of this ongoing project in reaction to multiple, exciting, concurrent national initiatives directed at improving birth outcomes and reducing infant mortality. Some of these initiatives include the MCHB Collaboration and Innovation Network (COIN) in regions IV and VI, the Association of State and Territorial Health Officials Healthy Babies Challenge, and the Center’s for Medicaid Services Strong Start Initiative. These initiatives create a current environment of opportunity which provides partners at the state and local levels significant leverage to make coordinated improvements to birth outcomes and, subsequently, overall population health. AMCHP will provide state teams selected for the ALC with direct training on collective impact in order to coordinate participation in multiple initiatives. In particular, the project will offer ALC states:

  1. Ongoing technical assistance to develop and implement strategies for using a collective impact framework to improve birth outcomes through health reform
  2. A forum to network, share ideas and problem solve with colleagues nationwide working on improving birth outcomes through health reform
  3. Information from leading national experts in various fields (i.e., collective impact, improving birth outcomes including preconception health, and health reform)

These three project areas – Best Babies Zone, the Adolescent Systems Capacity Tool and the Optimizing Health Care Reform to Improve Birth Outcomes project ALC – are examples of how AMCHP is actively promoting the principles of collective impact. By thinking about how we collaborate with partners and provide opportunities to members that enhance their ability to coordinate activities across multiple priority areas, AMCHP hopes to enhance our contribution to a collective MCH health system across the country.