Engaging communities to reduce health inequalities: why partnership?

• Author: Matheson, Anna

Abstract

The current policy trend to have the reduction of health inequalities as a desired outcome indicates a serious attempt to deal with the complexity of social interactions. In New Zealand in recent years the landscape for government-community relationships has also changed significantly. The prescriptive contracting environment of the 1990s has been replaced, in many policy areas, by the rhetoric of partnership. In theory, partnership seems to offer policy makers a way to respond to complexity in a flexible manner, and is perhaps a way to cope with levels of uncertainty in implementing policy. This paper discusses the background to the rise of the concept and the practice of partnership in New Zealand and gives examples of how it is currently being used. This is followed by a discussion of common themes identified from an extensive literature review. These themes are: the connection between partnership and participation; the impact of trust and power in relationships; the importance of local knowledge to understanding the local context; and understanding the capacity of communities to change. The paper concludes with a discussion of these themes and their relevance within both community and government settings. It recommends that to do justice to ideas of working in partnership to address complex social problems, such as reducing health inequalities, the theory and practice need to be considered far more carefully than they have been so far.

INTRODUCTION

Reducing health inequalities as a desired outcome for health and social policy interventions in New Zealand is a relatively recent phenomenon. It has emerged alongside other policy area definers such as "intersectoral action" and "whole of government" approaches, which also take a connected and longer-term approach to problem solving. This growing concern to reduce health inequalities brings with it some underlying assumptions, including the social environment is an influential factor in determining health outcomes; society is interrelated and connected; and solutions to reduce health inequalities need to be systemic. The parallel rise in popularity and use of partnership approaches (defined or otherwise) to achieve social goals reflects this new emphasis on the importance of social connections and relationships.

This paper outlines developments in the use of the term "partnership", particularly in relation to social goals such as reducing health inequalities. After a brief introduction to health inequalities it describes the background to the rise of partnership in New Zealand and gives examples of how it is currently being used. This is followed by a discussion of common themes relevant to partnership that have been identified based on an extensive literature review. The paper concludes with some discussion on these themes and their application for decision and policy makers.

The impact of the social environment on health can be seen in the extremely powerful and enduring relationship between health and social and economic inequalities (Dew and Kirkman 2002). Considerable research effort has gone into describing health inequalities, understanding their causes and trialling interventions to reduce them (Ajwani et al. 2003, Mackenbach and Bakker 2002). Both nationally and internationally, reducing inequalities has become a desired outcome for government policy, not least in the area of health.

Our understanding of health inequalities has its roots in the discipline of epidemiology, which has appeared over the last century in a number of guises (Berkman 2004). Epidemiology measures the distribution of disease, with early studies finding social variations in the incidence of many diseases. More recently, social epidemiology has taken this further by exploring the distributions and relationships of social characteristics and disease. The picture created by social epidemiology graphically illustrates the impact the social environment can have on people and their health. Characteristics such as socio-economic status, ethnicity, employment status and housing tenure, for example, have all shown relationships to health outcomes (Ajwani et al. 2003, Berkman and Kawachi 2000, Howden-Chapman and Tobias 2000).

Perhaps the earliest significant effort to influence governments regarding the necessity to look seriously at health inequalities was the Black Report. It was presented to the United Kingdom Government in 1980 and highlighted the statistical evidence of the relationship between the social world and disease. As a consequence, equity in health and a reduction in health inequalities were incorporated as targets for the World Health Organisation to achieve by the year 2000 (Howden-Chapman and Tobias 2000).

In New Zealand, since the Labour-led coalition government came into power in 1999 the landscape of government-community relationships has also significantly changed. The arms-length, outputs-focused, prescriptive contracting environment of the 1990s has been replaced, in many policy areas, by the rhetoric of partnership as a means of delivering social goals. The idea that communities themselves are integral to finding solutions to complex social issues has become popular, particularly when dealing with social and health inequalities, and also that if government "partners" with communities the solution will be more valid, long-lasting and meet local need. A number of key government documents have been developed that emphasise the quality of the relationships with non-governmental organisations (NGOs) and community organisations. Although the term "partnership" is only sometimes explicitly used, the words and ideas such as trust, respect and reciprocation, written in these documents, denote a particular set of values attributable to these relationships (Department of Prime Minister and Cabinet 2001, NZAID 2003, Treasury 2003).

The New Oxford Dictionary of English defines partnership as "an association of two or more people as partners" (Oxford University Press 2001), and when examples are provided they are in the context of business relationships, with the purpose being to manage profit and loss. A definition of partnership where its purpose is social intervention is more complicated to define. Partnership in this instance is either not defined or described in terms of the methods used for the intervention. An example of the latter can be seen in "community-based participatory" research, where partnership approaches aim to include the community context and community voice in the generation of knowledge. Doing this successfully requires such things as trusting relationships, longer time frames, mixed methods of inquiry and the sharing of costs and benefits (Israel et al. 1998, Minkler and Wallerstein 2003).

The language of partnership is used widely in the public and community sectors, although it is clear that agreed definitions of partnership are hard to come by. Still, the use of the term "partnership" in delivering social interventions has become relatively commonplace in the last few years. A Ministry of Social Policy (3) (2000) review of these partnership models highlights the difficulty in determining whether "partnership models" are effective in attaining social goals:

The literature does not answer the question of whether partnership models offer any benefits over other models in terms of achievement of welfare goals. (Ministry of Social Policy 2000:3) There seem to be three main reasons for the difficulty in answering this question. The first is the lack of theory around why a "partnership" relationship might be more appropriate in certain circumstances. Secondly, there is a lopsided concentration on communities and community organisations in discussions on partnership in a social intervention context; often the part played by government organisations or other institutions is left unanalysed. Thirdly, because "partnership" is usually used in situations where problems are complex and it is difficult to "prove" outcomes in a more traditional sense, it is hard to find measurable benefits of the partnership.

PARTNERSHIP IN NEW ZEALAND

A number of factors have influenced the current use of the term "partnership" in New Zealand. These include partnership as represented by the Treaty of Waitangi; the historical New Zealand government relationship with the NGO/community sector; international trends stemming from ideas such as social inclusion, social exclusion, social capital and a greater acknowledgement of the "third sector"; and the growing use of inclusive methods for social change, such as community development.

Unique to New Zealand is the specific use of "partnership" in relation to Te Tiriti o Waitangi (the Treaty of Waitangi). The Royal Commission of Social Policy (1988) summarised the three Treaty principles as participation, protection and partnership. The Court of Appeal's decision on the disposal of Crown land in 1987 also established a principle of partnership, which required the Crown to consult and act in good faith. This legal opinion underpinned a growing interest in partnership as part of community development. Yet many Maori criticise this use of partnership as inappropriate to a Treaty analysis. Partnership in a legal sense is derived from contract law and seen in examples of company partnerships, where...