Collaboration sounds like a great idea. The dictionary defines collaboration as: "working jointly with others." That sounds good, but it is important to be clear whether collaboration is the goal or a means toward an end. Briefly stated, the goals described in the three projects in this section are: (1) to increase collaborative leadership; (2) to involve New York city communities in improving health; and (3) to engage residents of Sitka to create a new approach to community health. In each case, it was unclear whether collaboration was the goal or a tool to use toward a different end (e.g., improving health). For example, the Wilson article demonstrated some confusion over whether collaboration was the goal or a means, stating at one point "our mission is to 'increase collaborative leadership capacity across sectors at all levels'" and at another "collaborative leadership is not a panacea; it will not work in all circumstances."

Collaboration as a process for engaging groups may be a very worthy goal, but an important question is whether it is used based on values or evidence of improved outcomes. A group may decide to use a collaborative process because the members value consensus-collective responsibility-and want to take the time to recognize and appreciate the contributions made by all group members, or the decision may be based on evidence that a collaborative process is the best way toward another goal-such as improved service delivery in a community, more efficient use of resources, or broader service of all constituents. In fact, there is conflicting evidence about whether collaboration is effective in achieving desired ends. Harbin et al 1 found that health outcomes were related positively to more comprehensive and coordinated services delivery models, but Glissen and Hemmelgarn 2 found that organizational climate rather than interorganizational coordination affected service quality.

Part of the problem is that until a group has defined its goals explicitly and clearly, the desired outcome may be so nebulous that it is unclear what tools may be useful in reaching those goals. Goals such as "creating a new approach to community health" or "improving health" are so vague that it is unclear what exactly the goals are and unclear what processes are best to achieve these goals. First, the goals must be better defined. Much of the work described by the authors in this section was to better define the goals by developing a collective agenda in New York City.

Collaboration is not measured so easily. 3-6 Most authors incorporate the concept that collaboration is a process and has stages of development. Collaboration usually starts with cooperation that leads to coordination and finally collaboration. The more advanced stages of collaboration include joint agreements and funding streams. Alter and Hage 3 proposed a model with three forms of interorganizational networks: (1) obligational networks that are informal and loosely linked; (2) promotional networks that share and pool resources; and (3) systemic networks that are formal interorganizational units jointly producing a service or product. Gray 4 writes that the impetus for collaboration may be resolving conflict or advancing a shared vision. She points out that there are various expected outcomes from collaboration including information exchange and joint agreement. It could be useful for each project reported here to examine its impetus for collaboration and expected outcome as well as the degree (or stage) of collaboration it seeks to achieve.

In the Sitka community collaboration, Cavanaugh et al describe a number of factors they found necessary for successful collaboration including trust, openness, consensus decision making, and time (because collaborative processes are time consuming). These are similar to factors found in the literature related to successful collaboration. Factors within systems that have been found to foster collaboration include a positive attitude toward collaboration and the perception that the benefits of collaboration outweigh the costs. 3,7 The quality of leadership of a coalition, the participation of stakeholders, and a participatory planning process are also characteristics of successful collaboratives. 1,8,9 Shared goals and values, a history of successful relationships, clear communication, availability of necessary resources (including time, staff, and expertise in maintaining collaboration), technical assistance, geographical proximity, and an awareness of other potential partners have been found to facilitate collaboration. 8,10

Factors affecting collaboration have been described as internal or external to a system. Alter and Hage 3 discuss three external variables affecting collaboration: (1) resource dependence (the degree to which political and economic forces impact the system), (2) regulations, and (3) the voluntary nature of client input into the system. Harbin et al 1 describe the process and outcomes of service delivery as dependent on the service delivery system, the skills and characteristics of the service providers, skills and characteristics of families, community context, state context, state policy, and leadership. The Cavanaugh article focuses primarily on internal factors that affect collaboration whereas the other articles focus on internal as well as external factors.

A number of studies 3,4,11 indicate that collaboration is not always an appropriate problem solving technique. Gray 4 reports several circumstances when collaboration will not be effective including: when a lead agency cannot be found; when there is a history of repeated ineffective interventions; when there is a substantial power differential among individual or groups of stakeholders; when there is a history of antagonism between stakeholders; or when conflict has caused overload for partners. Other barriers to collaboration that have been identified are: (1) lack of time to devote to collaboration efforts; (2) turf issues-particularly as related to scarce funding resources; and (3) confidential information sharing across agencies. 10 Cavanaugh et al found that time was a significant issue for their collaborative efforts, both the time required to get members together to work and the fact that consensus decision making is time consuming.

So to paraphrase Wilson, collaboration is not a panacea. The process of collaborative work seems to be energizing and have merit in its own right-as evidenced in these three articles. However, in a world of limited resources, there still needs to be better evidence about outcomes related to collaboration. The Robert Wood Johnson Foundation and W.K. Kellogg Foundation Turning Point initiative has funded new collaborative efforts. Now it will be important to evaluate these efforts in a way that enables better understanding of which collaborative processes work well, in what circumstances, and to what ends.

REFERENCES