When responding to the survey, the former HCAP community coalitions reported on several items related to the size and composition of the coalition membership, including membership turnover and membership diversity. Sustained coalitions provided responses regarding the current membership characteristics while not sustained coalitions responded with information about the coalition at the time the coalition disbanded. No statistically significant differences emerged between sustained and not sustained coalitions in terms of the number of member organizations and the proportion of those members considered active in the coalition. Sustained coalitions are comprised of 40 member organizations, on average, with 79 percent of members considered active. Not sustained coalitions were comprised of 22 member organizations, on average, with 74 percent of members considered active. Membership size ranges from 3 to 500 members for sustained coalitions and was 2 to 125 for not sustained coalitions at the time the coalition disbanded.
|Tracking Different Levels of Partnership in One Large Sustained Coalition|
|A sustained coalition in the Midwest has around seventy-five member organizations—sixty of which are active members. In order to manage its large size, the coalition developed a rubric to measure the varying levels of involvement from partner organizations. There were three levels of partnership under the rubric. A Level 1 partnership generally referred to a loose partnership consisting of a one-time, in-kind exchange, e.g. hosting a conference together. A Level 2 partnership involved a one-time exchange of resources that were not just in-kind, e.g. a one-time exchange of money. A Level 3 partnership suggested an ongoing exchange of resources, both financial and in-kind. When the coalition was formed, about sixty percent of members were Level 1 or Level 2 partners, and forty percent were Level 3 partners. Today, most of the coalition’s members are operating as Level 3 partners.|
In discussing coalition membership, key informants emphasized the importance of coalition quality and cohesion—having the right people participating in the coalition is more important than having the most members. A key informant from a coalition that was not sustained reflected that:
If we had a smaller group to define what we want to do and work on…[we] could have brought the pertinent people right away, and worked towards [our] goal more quickly...You don’t need a lot of people. It’s better to have five than thirty if you can actually accomplish something.
For larger coalitions, members played a number of different roles. Some members were more active than others, and contributed by providing in-kind resources, financial resources, and frequently, some combination of both.
Membership turnover. Exhibit 8 shows the data on the frequency of and reasons for membership turnover in terms of organizations leaving the coalition or new organizations joining the coalition after the formation of the coalition, for both sustained and not sustained coalitions. As illustrated in Exhibit 8, there was a low turnover of coalition members. The modal category for both sustained and not sustained coalitions was less than once every two years. Less than 10 percent of sustained and not sustained coalitions reported the addition of new members on a quarterly basis or more often. There were no statistically significant differences between sustained and not sustained coalitions on this measure.
Panel B shows the frequency of members leaving the coalition for sustained and not sustained coalitions. Overall, the loss of members was infrequent with over 80 percent of coalitions reporting the loss of a member no more than once every two years. On this measure of turnover, however, there are significant differences between sustained and not sustained coalitions (p<.01). A majority of not sustained coalitions, 57 percent, reported never losing members compared to 35 percent of sustained coalitions. Sustained coalitions were more likely to report very minimal turnover with 49 percent reporting the loss of a member less than every two years compared to 24 percent of not sustained coalitions. One sustained coalition explained the importance of early buy-in for maintaining members. Within this coalition, members were engaged from the initial development of the program, which gave them a sense of ownership. Furthermore, member organizations, rather than specific staff members, "owned" a seat on the board. This meant the organization maintained membership in the coalition, even if there was staff turnover within the organization. A key informant from this coalition noted: "As we developed the bylaws…we defined [on the] board of directors, the organization owns the seat...They sit as an organization because you can have turnover but you have that organization committed."
Additionally, as shown in Panel C, the reasons for coalition turnover varied significantly by sustainability status (p<.05) with sustained coalitions more likely to say turnover was related to issues with the member organization rather than the coalition. Thirty four percent of sustained coalitions cited changes within the member organization as the most frequent reason for turnover compared to 20 percent of not sustained coalitions. Coalitions that were not sustained cited coalition funding and a reassessment of membership needs and priorities slightly more often than sustained coalitions. Furthermore, as noted in Panels A and B, not sustained coalitions were more likely to say there was no turnover (33% compared to 25% of sustained coalitions).
Exhibit 8: Coalition Member Turnover>
Panel A: Frequency Members Join Coalition
Fisher’s Exact p<.01
|Frequency of New Members Joining||% Sustained Coalitions (n=113)||% Not Sustained Coalitions (n=52)|
|Less than once every two years||41||31|
|About once a year||28||25|
|About once every six months||12||12|
|About once every three months||4||6|
|More than once every three months||6||6|
Panel B: Frequency Members Leave Coalition
Fisher’s Exact p<.01
|Frequency of Losing Members||% Sustained Coalitions (n=113)||% Not Sustained Coalitions (n=51)|
|Less than once every two years||49||24|
|About once a year||12||10|
|About once every six months||4||8|
|About once every three months||1||0|
|More than once every three months||0|
Panel C: Reason for Turnover
Fisher’s Exact p<.05
|Reason for Member Turnover||% Sustained Coalitions (n=113)||% Not Sustained Coalitions (n=51)|
|Changes in coalition funding||8||12|
|Shifts in projects and activities||18||18|
|Reassessment membership needs and priorities||8||12|
|Changes within the member organization||34||20|
|Not applicable, no turnover||25||33|
Membership diversity. Coalitions were asked to note the types of organizations and sectors represented in the coalition membership. The options included a list of 26 different types of health organizations, as well as seven other sectors (government, social services, education, faith, business, foundations, and other). Overall, there was a great deal of diversity among both sustained and not sustained coalitions, as shown in Exhibit 9. Sustained coalitions showed signficantly more diversity within the health sector than not sustained coalitions (p<.05). The average number of health organization types was 9.9 for sustained coalitions with a range [1, 21] compared to an average of 7.9 for not sustained coalitions with a range [1, 24]. Sustained coalitions were signicantly more likely to have members representing several types of health organizations including public or private practices and providers; medical or dental associations; specialty care providers; school based health centers; migrant health centers; managed care organizations; Medicaid programs; laboratories; long-term care providers; and community based organizations. Key informants emphasized the need to engage diverse health providers from the community. A representative from one coalition said, "we definitely have to stay connected with the administration or leader of the local health facility (hospital or FQHC), health department, etc." Another said, "The hospitals need to be [involved], the county needs to be [involved],..[we] need to get funders and providers involved."
|Types of Sectors and Organizations Members Represent||Number Sustained Coalitions||% Sustained Coalitions||Number Not Sustained Coalitions||% Not Sustained Coalitions|
|*p<.10; **p<.05; ***p<.01, two-tailed difference of proportions test|
|Health Sector Members Represent:|
|Federally Qualified Health Centers||100||90||45||88|
|Hospitals with a low-income utilization rate greater than 25%||82||74||39||76|
|Free clinics/other community health centers||76||70||31||61|
|Public or private health care providers/ practices**||70||64||24||47|
|Mental health programs/providers||64||58||23||45|
|Academic medical centers||56||51||25||49|
|Specialty care providers***||49||45||9||18|
|Oral health providers||41||38||15||29|
|Substance abuse programs||38||35||13||25|
|School-based health centers**||34||31||8||16|
|Managed care organizations*||33||30||9||18|
|Area health education centers||31||29||17||33|
|Primary care associations||27||25||18||35|
|Rural health clinics||27||25||11||22|
|Home health providers||26||24||7||14|
|Other health care coverage programs||21||19||8||16|
|Migrant health centers*||20||19||4||8|
|Long-term care providers*||16||15||3||9|
|Private insurance providers||16||15||6||12|
|Public housing primary care programs||12||11||5||10|
|Non-Health Sector Members Represent:|
|Government (e.g., local health department or elected officials)||86||77||40||78|
|Social services (e.g., juvenile justice programs or temporary housing assistance)*||55||50||18||35|
|Education (e.g., elementary schools or university public health programs)||48||44||18||35|
|Foundations (e.g., philanthropic organizations)||44||40||15||29|
|Faith (e.g., churches or faith-based organizations)||42||39||17||33|
|Business (e.g., chambers of commerce or local nonprofits)||30||28||11||22|
|Other (including ambulance/ems, public housing, agriculture, individual community members, and interest/advocacy groups)||16||15||4||8|
Looking across health and the seven other sectors in Exhibit 9, the average number of sectors represented in the membership of sustained coalitions was 3.9 with a range of 1 to 8. Similarly, the average number of sectors represented in the membership of not sustained coalitions was 3.4 with a range of 1 to 8 . The government sector was the only non-health sector represented in a majority of the coalition memberships by 77 percent of sustained coalitions and 78 percent of not sustained coalitions. Sustained coalitions (50%) were more likely to have members representing the social services sector than not sustained coalitions (35%, p<.10).
Diversity of Membership as a Facilitator of Sustainability
|One sustained coalition that participated in a site visit explained that a major facilitator of their success and sustainability is the diversity of their membership. The two major hospitals, their respective clinics, and a local federally qualified health center were the major players, but the state department of mental health and addiction, the local homeless shelter, other specialists, laboratory and diagnostic service providers, and the local social services agency provided needed wrap-around services for the under/uninsured population served by the coalition.|
Several other coalitions noted the importance of involving partners that are not historically connected to the cause. For example, a representative from a sustained coalition that participated in a site visit noted: "We definitely have to stay connected…we have typically partnered with community development organizations, which not only have manpower and resources that can be used, but [can also] connect you beyond those people who have a personal invesment in health care." Similarly, a key informant from a not sustained coalition said: "[You] can’t sell this program to mission folk, social service, mental health folk. They get it, what you have to do is convince the finance and provider folks. If you got them on board, you’re good to go."
While membership diversity helped some coalitions to expand services available to the target population, other coalitions experienced conflicts resulting from this diversity. A representative from one coalition that was not sustained commented on this fragmentation:
Members were some businesses, insurance-oriented people, and there was representation from faith-based, public health, health care….but I think each of us perceived our roles in the coalition with our organizations’ hats on. We did not perceive the activity as…’how we could make the community better?’ We all perceived our role as…’how can we make [our] organization better?’
Other coalitions did not experience this fragmentation, and found that their member organizations were able to come together, and put their own agendas aside, to discuss issues that affect the community. For example, one sustained coalition commented: "[The coalition] is recongized as an organization that is totally neutral—all of the people on our board are really competitors, but they do not sit in a competitive mode when they are in the [coalition] mindset."