Rapid Review: Using collaboration to take on complex community health issues and create social change

What you need to know

  • Agencies, service sectors, and citizens are using collaboration to address complex community health issues, with varying levels of success.
  • There are different types of collaborations, including interagency partnerships, collective impact, and community collaborations.
  • Collaborations differ across communities and contexts, but they have common features that make them effective and sustainable.
  • Putting these features into practice requires great effort.
  • At the heart of collaboration are positive relationships.
  • Resources need to be allocated in ways that are fair and accessible.


What’s the problem?

In the health and social services sector, collaboration means “any joint activity by two or more agencies that are intended to increase public value by working together rather than separately.”1(p8) Today, there is a growing understanding that the issues these sectors face are complex, and that coordinated action is needed.2 Collaboration is being used to tackle areas such as childhood obesity,3,4 HIV,5 high blood pressure,6 cancer,7 broad community health priorities,8 severe mental illness,9-11 illicit drug use,12,13 homelessness,14 and domestic violence.15

These sectors have been affected by duplication, fragmentation of services, competition, and distrust.16-18 While there is a need for collaboration, and decades of findings on the subject, research from different academic disciplines often is not used to inform collaboration efforts.19 In addition, many efforts fail to reach their full potential or struggle to maintain benefits for everyone involved.16,20

There remains a need to better understand how collaboration can help address complex social or community health issues.

What were our objectives

An EENet knowledge broker conducted a rapid review of the literature to capture the best available evidence related to collaboration in community health. The guiding questions were:

  • What contributes to effective collaboration for community health systems?
  • What factors help or hinder collaborations that aim to address a complex community health or social problem?


We paid special attention to factors that contribute to system change or transformation. System change refers to the process of changing the way things are routinely done by changing the way a system works and functions.21 We also looked at collaborations that seek to solve “wicked problems,” that is, social or community health problems that have no “best” solution and whose dynamics change over time as a result of efforts to solve them.22

Read our findings below or download the PDF.

What did we do?

Working with a CAMH librarian, we explored the following academic databases: Pub Med; PsychINFO; scholar’s portal; Cochrane Systematic Reviews; and Google Scholar. We looked for articles published between 2007 and 2017. Key search terms included “community collaboration,” “inter-agency collaboration,” “inter-organizational collaboration,” “systems change,” and “systems transformation.”

We gave priority to systematic reviews as well as well-known and respected articles on the subject, as indicated by the number of times cited.

We only included articles where collaboration involved at least three agencies, particularly those in community health and social services. We excluded any articles conducted outside North America, New Zealand, Australia, and Western Europe. We also excluded articles focused on collaboration in primary care, educational curriculums, professional training programs, community-based participatory research, and community-university partnerships.

We examined collaboration best practices in the context of systems of care, community-based health care, public health, and health promotion. We also included systems of care if the majority of those involved were:

  • community service organizations
  • citizen groups
  • individuals with lived experience of a health or social issue, and/or
  •  individuals using services that provide help related to a social or community health issue.


We retrieved 1,814 articles from the initial search and reviewed the titles and abstracts of the first 1,000 against our selection criteria. We reviewed articles included in the initial round further, to ensure they were eligible. A total of 294 articles passed the second screening stage and met the selection criteria. These were sorted according to themes, and then analyzed and synthesized. 

What did we find?

We organized the findings for the first research question (What contributes to effective collaboration for community health systems?) according to the following themes: “community context;” “values and principles;” “collaborative processes;” “collaborative structures;” and “collaborative outcomes.”

For the second research question (“What factors help and hinder collaborations that aim to address a complex community health or social problem?), we organized the findings according to themes, as described below and summarized in tables 1 and 2 (at right). While collaboration outcomes are included in the first table, they are discussed separately near the end of this document. We organized the document this way because findings from both research questions influence how, and to what extent, these outcomes happen in practice.

Table 1. What contributes to effective collaboration?
To enlarge click on image

Research question #1: What contributes to effective collaboration for community health systems?

Community context

The most successful collaborations pay attention to the community from the beginning of the project.23 The context influences the processes and decision-making structures used,24 as well as the outcomes emerging from the project.5,7

Communities that have worked together before are the most ready to collaborate with each other. Previous working relationships create a sense of ease and trust.25-41 Neighbourhoods with a history of community collaboration allow residents to provide input into decision-making and develop their skills in a number of areas (e.g., grant writing; research; public speaking).13,16,17 These empowered communities also have control over how issues are viewed and dealt with.4,6,7,20,40,42-46 Communities that have a common desire for change are often more successful at collaborating.40,44,47-55

Previous working relationships offer benefits that last throughout the community change process.25-30 They also enhance coalition functioning39 and promote a sense of community.40 Communities that have experience working together resolve conflict and competing interests more quickly.33 Participation in decision-making helps promote the well-being of residents.40,56-58 When citizens and professionals have a common desire for change, this often leads to changes in organizations, programs, and the community.59 Communities with a common desire for change help improve the skills of the group,40 influence implementation processes,50 and increase the chances that the intervention will live on.60

Collaborative values and principles

Collaborative values and principles are the philosophies that motivate the behaviours and attitudes of the people involved. They provide insight into how the social or community health issue is viewed.  They also help identify the skillsets or strategies that are best suited to address them. These values and principles include:

  • social justice and equity, as well as having a shared vision13,17,25,35,54,55,61-67
  • respect for diversity and promotion of cultural competency26,27,32,68-74
  • systems thinking75-79 to better understand the root causes of community issues3,77,80,81 and to create  innovative solutions.35,62
    Table 2. Barriers and facilitators to effective
    To enlarge click on image


Collaborative processes

Collaborative processes are a series of actions carried out by a collaboration,24 or aspects of activities that influence how a collaboration functions.25,26 The following factors can have a positive impact on collaborative processes:

  • Building and maintaining relationships.1,7,30,31,73,82-88
  • Building capacity.1,3,17,26,89-100
  • Clear and continuous communication.13,14,16,20,25,28,30,33,35,39,55,69,83,101-104
  • Coordinating actions and activities.17,18,26-28,54,105-109
  • Technical assistance.12,13,20,28,29,32,45,50,53,54,84,101,110-118


Building and maintaining relationships is often essential to collaborative action,119 encouraging people to share resources104,108 and increasing the benefits of technical assistance.32 They also improve health system outcomes85,120,121 and promote the coalition’s sustainability.120

Opportunities for capacity building are also important as they allow members to improve their performance and meet objectives.117 Building the skill sets of regular people originates from the recognition of differences in wealth, status, and social class.34,43,119 The most successful partnerships recognize these differences among members , and take steps to address them.78,99,119,122

Many successful collaborations offer skill development training121,122 and help members obtain graduate degrees through their engagement with the initiative.122 These opportunities offer several benefits, such as increased commitment to the process,40 better program performance,99 and improved problem-solving.117 They also improve people’s grant-writing and policy development skills.123 Initiatives that build peoples’ capacity also have carry-over effects.12,60,63 A focus on building people’s capacities enhances the collaboration’s functioning63 and sustainability,12,13,60 and is associated with improved health outcomes.121

Maintaining clear, continuous communication increases people’s readiness for action,124 promotes positive working conditions,97 and has a positive influence on project outcomes.121 Clear communication also helps build trust,17 promotes effective use of resources,102 and provides opportunities for continuous growth and learning.79 While information sharing is limited in its ability to change practice or policy, most collaborations still focus on this activity.104

Coordinating actions—making sure that intervention activities offered across agencies complement each other—is part of the collective impact approach, a type of collaboration that is used to address complex social problems.125,126 Coordinating actions across agencies helps organizations overcome their desire to work alone18,54 and increases the number of people involved.29

Providing technical assistance, such as professional training opportunities, helps implement evidence-based programs.13,32,110,127,128 It also helps build trust118 and promotes the project’s sustainability.60 The most effective approach involves demonstrating the technical skill and having trainees practice them with coaching support.13 Technical assistance is less common than information sharing.104

Collaborative structures

Collaborative structures are often referred to as the “container” or “sandbox” where collaborative action occurs.24,129 They are sometimes viewed as leadership or decision-making.46,130 Some authors mentioned that well-defined structures are needed for collaborations to work well.130 Others suggest that collaborative structures need to adapt and change over time based on the community’s current stage of implementation and social conditions,131 and the needs of those receiving services.78 In this category, several techniques can promote good collaborative functioning. They include the following:

  • Collaborative, working group agreements such as memorandums of understanding and terms of reference.7,10,31,72,83,106,131-136
  • Inclusive and participatory settings.7,11,17,25,28,29,31,34,40,51,52,83,101,115,132,137
  • The presence of systems leaders.6,7,16,17,25,26,28,30,82,83,95,101,106,138,139,140
  • Dedicated spaces for experimentation, innovation, and testing.6,42,54,65,117,141
  • Shared or consensus decision-making.1,6,10,32,39,42,49,74,92,117,142,143


These techniques are associated with a number of benefits. For example:

  • Collaborative working group agreements help manage conflict69,131,144 and bring clarity to the work.6 These agreements define the project boundaries and help decide who needs to be involved.76,117  While working group agreements are helpful for administrators,104 they do not guarantee that the work will run smoothly.104,145
  • Inclusive settings help collaborations run smoothly83 and promote community goals40 by involving diverse people.34 Inclusive settings help ensure interventions meet community needs.146
  • Systems leaders help resolve conflict1 and smooth implementation and scale-up processes.53 Leaders often bring needed change to organizations55,59,140 and improve the sustainability of projects.12,50,74  Spaces to experiment, innovate, and test can help people change their thoughts, behaviours, and attitudes.42,65,141 Shared decision-making fosters a sense of community119 and helps collaborations work well together83,86 through engagement with, and getting buy-in from, diverse people.39

Research question #2: What factors help and hinder collaborations that aim to address a complex community health or social problem?

Barriers to effective collaboration

Several barriers to collaboration can threaten the sustainability of a collaboration (Table 1).30,35,44,46,55,136,147 For example:

  • Competing priorities.28,42,49,61,123,140,147,148
  • Role ambiguity.28,61,144,149
  • Resource and time constraints.16,27,28,41,48,60,90,117,132
  • Staff turnover,28,38,59,101,140,148,150 resulting in loss of knowledge and preventing fair decision-making.151
  • Power imbalances, such as between professionals and clients.16,28,61,83,92,152,153
  • Costs of participating being greater than the benefits.16,20,120,140
  • Lack of trust between partners.16,17,18,20,28,154
  • Limited and selective engagement of stakeholders.7,8,20,27,28,30,40,106,118,136,138,155,156
  • Lack of communication between stakeholders.28,29,83,114
  • Funding issues that affect implementation and sustainability of activities.136,147
  • Use of theories of change that focus solely on individual behaviour.35,55


With so many factors impacting sustainability, this topic has become a subject of intense study.12,44

Facilitators of effective collaboration

On the other hand, many factors have a positive influence on coalition functioning and outcomes (Table 2). For example:

  • Commitment to continuous learning and evaluation.13,35,47,52,54,61,101,114,132,136,151,157-159
  • Organizational flexibility, reflection, and openness to change.3,26,51,65,74,141,160,161
  • Exchange of knowledge and resources among partner organizations.1,16,17,24,41,55,90,115,119,149,151,162,163
  • Engagement of diverse people.7,16,17,28,29,41,42,69,83,90,106,115,149
  • Trust between partner organizations and individuals.33,35,42,48,88,164,165
  • Common interests and a common agenda over time.7,16,18,25,26,28,35,42,49,69,83,97,120,164-166


While engaging diverse people offers many opportunities for learning, it requires skillfully navigating conflict—making efforts to understand peoples’ points of view, concerns, and reasons for disagreement.69 The use of data-sharing agreements and efforts to change the roles and responsibilities of people involved also prompts―and is indicative of―continuous learning.78 By building the capacity and skills of those involved (e.g., in research, group facilitation, reflection, etc.), organizations can become more open to change.167

Organizations that exchange knowledge and resources more readily influence the collaboration’s growth and development by communicating and sharing best practices, and by helping agencies and individuals understand where their efforts would have the most impact.55 Similarly, this exchange also can help predict where and how future funds will be used.39

Facilitators of knowledge and resource exchange include creating opportunities for staff training, having supportive management teams, and using systems that store and share knowledge.168 One study of inter-organizational networks found that agencies with higher caseloads and agencies in urban centres were more likely to share information.1

There are many benefits to involving a variety of agencies and people (e.g., across sectors and professional backgrounds). Working with diverse people helps organizations build a broad range of skills119 and positively influences peoples’ perceptions (e.g., clarifying misunderstandings between different professional backgrounds/sectors and views of clients).28 Collaborations that bring people together from across a community also have members who have greater capacity for systems thinking.76 These collaborations were also more likely to be sustainable60,123 and to achieve the desired health outcomes.29

Many organizations tend to work only with agencies like their own, which supports a sense of community and encourages resource sharing but also limits participation.18,106,142,169 On the other hand, those who are most willing to cooperate and compromise are more likely to find common interests.35,170

Outcomes of effective collaboration

The list of considerations for effective collaboration seems daunting, but the payoff can be significant (see the list below). In some cases, collaboration facilitators and outcomes are similar (take for example, the case of empowerment and capacity or skill building). This likely reflects the complexity, differences in measurement, and reality that some components are both processes and outcomes.39 The main outcomes of collaboration include:

  • Increased funds and resources.59,66,100,120,123,171
  • Increased empowerment and decision-making capacity.7,16,59,125,127
  • Implementation of evidence-based programs.7,13,20,50,53,77,85,87,172,173
  • Community, practice, or policy change.13,26,51,91,100,104,123,174-177
  • Increased project/collaboration sustainability.3,17
  • Increased professional development opportunities.27,59,122,175
  • Increased knowledge and awareness of the community health/social problem domain.3,4,7,27,34,59,65,83,86,127,178-180
  • Increased political advocacy (e.g., attending municipal hearings, etc.).91
  • Enhanced social networks.26,31,59,86,100,104,106,118,138,163
  • Reduced reliance on a central agency or actor.31,104
  • Increased trust among participants.101,104,123
  • Improved health outcomes for service users.6,28,35,43,51,60,87,91,100,111,150,181-183

What are the conclusions?

Collaboration holds promise as a way to solve complex community problems. However, outcomes often fall short when there is little or no planning and a lack of coordination and leadership. Collaboration also fails to achieve benefits when resources are poor, relationships are not nourished, and power imbalances and lack of trust are not addressed. Failing to attend to these issues often contributes to poor implementation, disappointment, and an untimely ending to the project. It is critical that future research on collaboration use standardized measurement approaches and coordination across disciplines.

How can you use these findings?

These findings may be useful to people who are working to address various large-scale social problems. Collaborations involving partners within and beyond the mental health and addiction system will likely benefit from considering the factors that lead to effective collaboration with people from diverse cultures, life circumstances, and service sectors.

What are the limitations of this review?

Despite using and refining robust exclusion and inclusion criteria, the large number of articles we found prevented us from investigating each article thoroughly and systematically. This issue was amplified by a lack of a second reviewer, which might have resulted in selection bias.


The author of this review is Brandon Hey (former Knowledge Broker for EENet). He would like to thank Sarah Bonato, CAMH librarian, for helping with the literature search and retrieving the list of articles reviewed. He would also like to thank Nandini Saxena (former Manager of Knowledge Exchange in the Provincial System Support Program at the Centre for Addiction and Mental Health [CAMH]) for supporting the work and for providing detailed comments regarding its content and formatting. Lastly, he would like to thank Rossana Coriandoli, EENet Communications Coordinator, for her plain-language review of this article and for helping to finalize it for publication.


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Rapid reviews are time-limited ventures carried out with the aim of responding to a particular question with policy or program implications. The information in this rapid review is a summary of available      evidence based on a limited literature search. EENet cannot ensure the currency, accuracy or completeness of this rapid review, nor can we ensure the efficacy, appropriateness or suitability of any intervention or treatment discussed in it. For more information contact eenet [at] camh [dot] ca.