Achieving improvements in population health is inherently a multi-institutional endeavor. For most contemporary public health problems, no single organization can offer the full complement of information, resources, and expertise necessary for improvement on a population-wide basis. This is so because the causes of most public health problems are multifactorial-involving the complex interactions of biology, environment, and human behavior; because governmental and private investments in public health, individually, are often insufficient to support sustained and comprehensive public health responses; and because the manifestations of public health problems frequently extend beyond the boundaries of a single state or local public health jurisdiction. Recognizing these facts, public health organizations increasingly have pursued collaborative relationships with other organizations as a way to pool resources and expertise to realize shared objectives in improving population health. 1-6

The Boundaries of Collaboration

Unfortunately, the realities of public health collaboration sometimes do not live up to their promise. Differences in institutional structure, mission, and culture often limit the range and type of organizations that are willing and able to cooperate in achieving shared public health objectives. 7 Some organizations are reluctant to commit substantial resources to initiatives over which they will have only partial control. Other organizations encounter difficulties in developing collaborative arrangements that allow for shared control and decision making without sacrificing the ability to act swiftly and decisively on public health issues. Governmental public health organizations often face cumbersome contracting, purchasing, and hiring regulations that limit their ability to develop flexible alliances with other organizations. Still other public health organizations encounter difficulties in creating participation incentives that attract sufficient involvement from community members and private institutions. Many collaborative efforts fail to consider the accommodations that may be necessary to attract and retain the participation of institutions operating outside traditional public health arenas such as business, health insurance, human services, education, public safety, and criminal justice.

Even organizations that are successful in implementing collaborative public health initiatives often find it difficult to sustain these endeavors over time. Changes in institutional leadership, political priorities, and funding streams can erode participation in collaborative initiatives. New opportunities can draw participants away from existing endeavors. In some cases, participating organizations may become disillusioned with collaborative ventures, particularly if progress toward shared objectives is slow. In other cases, collaboration may unravel after initial objectives are met, thereby precluding the organizations from refocusing their collective efforts on other public health issues.

Perhaps most importantly, collaborative ventures often fail to change in synchronicity with the natural evolution of state and local public health systems-including evolving population health needs and threats; the changing constellation of institutions that currently and potentially influence population health; and the shifting mix of interests, resources, and skills within these institutions. Consequently, even if collaborative ventures remain intact over time, they may exhibit an ever-diminishing impact on public health practice and population health outcomes.

Alternative Structures for Collaboration

In view of these challenges, some public health organizations have begun to explore alternative institutional structures for developing and sustaining collaboration in order to improve the practice of public health. The Turning Point Initiative launched jointly by the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation has provided impetus and opportunity for much of the recent exploration. These alternative structures are designed to broaden the array of institutions that contribute to public health improvement, to expand the scope of disciplines and fields engaged in improvement efforts, and to facilitate information exchange and learning among the involved organizations and disciplines. 8

In some cases, these alternative structures take the form of new partnerships and alliances that support a far greater scope of activity and authority than past multi-organizational efforts in public health. Montana's public health improvement initiative embodies this approach by bringing together a broad collection of public health stakeholders to develop a statewide strategic plan for public health improvement and to launch a public health training institute (see article by Reynolds and Leahy in this issue). In other cases, entirely new organizations are formed to serve as foci for new ideas, information, and collective action in public health. This tact is evident in the Turning Point initiatives underway in both Virginia and Louisiana, where new nonprofit organizations have emerged to mobilize and coordinate public health improvement activities across the public and private sectors (see articles by Peterson and Lake and Kimbrell et al. in this issue). Some consider these new structures to be a "fourth sector" in the public health system that bridges the interests and activities of government, academia, and the community. Within all of these efforts, communities are experimenting with new governance structures designed to encourage broad participation and to facilitate shared decision making around public health priorities and responses.

From Collaboration to Coevolution

The degree of success these alternative structures ultimately achieve in improving population health is likely to hinge at least in part on their ability to move institutions and communities beyond the relatively shallow and opportunistic forms of collaboration that most commonly are observed in public health practice. Ideally, these structures will enable institutions and communities to move from collaboration to coevolution in pursuit of a common interest in public health improvement. Coevolution occurs in biology as multiple species become ecologically interdependent by simultaneously adapting to their environment and each other, often resulting in a more stable and efficient ecological system. An analogous process is possible among organizations that face common interests and resource dependencies, 9-11 such as those that comprise state and local public health systems.

For coevolution to occur in public health systems, organizations are likely to require structures that promote broad-based information exchange and learning across professional disciplines and institutional domains of activity. They are likely to need interorganizational processes that allow continual adaptation of individual and collective efforts in public health to changing community needs. On this basis, the alternative structures now emerging through the Turning Point initiative hold much promise for achieving improvements in public health.

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