Given the complexity of the literature on the sustainability of community coalitions, this section defines what it means to be a sustainable community coalition. As depicted in previous chapters, community coalitions have different memberships, patterns of formation, functions, goals, activities, and organizational structures. As such, it is important to clearly define what is meant by the term “community coalition.”
A commonly used definition of community coalitions developed by Feighery and Rogers (as cited in Butterfoss, 2007, p. 31) defines a community coalition as "a group of individuals representing diverse organizations, factions, or constituencies within the community who agree to work together to achieve a common goal." To add specificity to the conceptual framework, the Feighery and Rogers definition is expanded to define the number of organizations. Thus a community coalition is defined as an alliance of three or more organizations who agree to come together to achieve a common goal. Adding the requirement of at least three organizations to the definition excludes direct partnerships between two entities from qualifying as a coalition, while ensuring the inclusion of coalitions of all sizes. This definition serves two purposes. First, by building on the well-accepted Feighery and Rogers definition, findings about the sustainability of community coalitions generated with this definition can be compared to other findings in the literature. Second, this definition is broad and will therefore be inclusive of community coalitions even if their form or function changed over time.
Next, it is necessary to define what is meant by the sustainability of a community coalition. Post initial federal funding, some community coalitions continue to function exactly as they did previously—with the same membership, goals, activities, managerial structures, intensity of collaboration, community buy-in, and vision. Others are sustained with a different composition of members, although the coalition is still continuing to address its original goals. Some community coalitions have the same composition of members, but have scaled back their work by addressing only one (rather than all) of their original goals. Other community coalitions continue to evolve since they were initially federally funded, addressing their original goals and expanding to work toward new goals. Some coalitions adopt entirely new goals as a result of a shift in the economic or political environment or in response to a change in the community’s needs. In addition, some coalitions dissolve because of internal problems, or actively disband because they have found new homes for their activities within the community (e.g., institutionalization of the benefits within the community) or because they have achieved their original goals. A definition of sustainability in the context of community coalitions must recognize these different scenarios.
In order to provide a foundation for the definition of a sustained community coalition, Exhibit 5.1 displays a sustainability decision tree.
Exhibit 5.1: Sustainability of the Community Coalition
Exhibit 5.1 This exhibit displays the decision tree that will be used to define whether a coalition is sustained, expanded, partially sustained, or not sustained coalitions. The text following the exhibit describes each branch of the decision tree.
At the most basic level, once the initial federal funding ends, the coalition is either sustained or not sustained. The sustainability of a community coalition is a function of two conditions that must be met post initial federal funding:
- The first condition of sustainability is that the coalition is composed of an alliance of three or more organizations.
- The second condition of sustainability is that the alliance of three or more organizations is working together to address one or more of its original goals (i.e., those goals that the coalition was working toward when the coalition was initially federally funded).
For the purposes of this conceptual framework, there is an important distinction between the community coalition’s “goals” and its “activities.” For example, the original goals of the HCAP community coalitions were connected to the vision of the coalition. These were commonly to increase insurance coverage and access to services for the uninsured and underserved, better coordinate and integrate services in the community, improve the quality of health care for the uninsured and underserved, and reduce the cost of care for the uninsured and underserved. The activities are the ways in which each coalition works toward its goals. Activities are unique to each coalition and may be refined over time to reflect the economy, funding priorities, population demographics, evaluation results, or other factors.
Thus, a sustained community coalition is an alliance of three or more organizations that are addressing one or more of the original goals of the coalition. It is important to note that this model assumes that there will be membership turnover in the community coalition. Thus, the alliance of three or more organizations does not need to be the same one that was part of the community coalition when it was initially federally funded. In other words, the coalition is considered “sustained” as long as it is composed of an alliance of three or more organizations that are working to achieve one or more of the original goals of the initially federally funded community coalition.
Furthermore, of the sustained community coalitions (i.e., those that have satisfied both conditions), some may be fully sustained, meaning that the coalition is addressing all of its original goals, while others may be partially sustained. A coalition is considered partially sustained if it satisfies both conditions of sustainability but is not addressing all of its original goals. For example, suppose a community coalition was originally working toward two goals: improving coordination among providers in the community, and reducing the cost of insurance for the underserved. After the coalition’s initial federal funding expired, it focused its efforts exclusively on addressing the latter goal to reduce the cost of insurance. Since the coalition is no longer addressing all of the original goals, this coalition would be considered partially sustained.
Similarly, some community coalitions may be continuing to work toward all of their original goals while also addressing a new goal. For example, a community coalition is addressing its original goal of improving access to services for the uninsured. Post initial federal funding, this community coalition continues to work toward this original goal but is also addressing a new goal: improving collaboration among social services organizations in the community. This community coalition would be considered expanded.
Community coalitions may also be partially sustained and expanded. These coalitions are partially sustained because they are addressing at least one of their original goals. However, they have also expanded because they have taken on at least one new goal. For example, suppose a community coalition had two original goals: reducing non-emergent emergency department (ED) usage in the community and expanding access to health insurance. In the meantime, another organization in the community received a large grant to address non-emergent ED use in the area’s primary hospital. As a result, the coalition decided to “drop” its original goal to reduce non-emergency ED use since the other organization had assumed leadership of this issue. Simultaneously, there was an increasing need for health education in the community. The coalition replaced one of its original goals with the new goal of promoting health education. Now, the coalition pursues health education and continues to expand access to health insurance. This coalition would be considered partially sustained and expanded. The new goal may or may not be synergistic to the original goals of the coalition. Rather, the new goal is reflective of the evolving needs of the community. Partially sustained and expanded coalitions have an important adaptive capacity, given that they have responded to community conditions over time.
Post initial federal funding, some community coalitions will not be sustained. The coalitions that do not have an alliance of three or more organizations, may have either dissolved because of a lack of resources, conflicts, or other reasons, or actively disbanded because they have achieved their original goal(s), and/or were no longer needed in the community. Additionally, in some cases, the coalition may have an alliance of three or more organizations that is no longer addressing at least one of the coalition’s original goals. This coalition is addressing a new goal, perhaps as a result of a shift in the economic or political environment or in response to a change in the community’s needs. Additionally, a coalition may address a new goal to meet the requirements of a new funder. Regardless of whether the coalition dissolved, actively disbanded, or is addressing a new goal to meet the needs of the community, the coalition is considered not sustained. Thus, even coalitions that have an active membership and/or were successful in institutionalizing the activities in the community may not necessarily be considered sustained.
Coalitions that are “sustained” in Exhibit 5.1 are composed of an alliance of three or more organizations that are working toward one or more of the coalition’s original goals. However, these coalitions are not necessarily pursuing their original activities, i.e., the same activities that they did when they were initially federally funded. Activities are the ways in which each coalition addresses its goals, and may include programs or services, systems, policies, health behavior interventions, dissemination of products, and community capacity building. Therefore, upon determining whether the coalition itself has been sustained, it is necessary to explore whether the coalition has been able to sustain all, some, or none of its original activities. Given that coalitions evolve over time, it is possible that activities will also change to reflect the needs of the community or the requirements of a funder.
Exhibit 5.2 demonstrates that all, some, or none of the original activities of the coalition may have been sustained, regardless of whether the coalition itself has been sustained. If all or some of the original activities are sustained, they can be sustained by the community coalition and/or a federal, state or local government entity. If the coalition conducted several original activities, some may have been sustained by the coalition while others may have been sustained by government or non-government entities.
There are several reasons that explain why none of the coalition’s original activities are sustained. First, the coalition may have lost its funding, or alternatively, the funder may have changed its priorities, affecting the original activities. Second, there may have been a change in the target population’s demographics that required the coalition to conduct different activities. Third, evaluation results or new evidence-based data may have suggested the need for changes to the coalition’s activities.
Below are three hypothetical cases of community coalitions whose activities have been sustained after their initial federal funding has ended. In the first case, all of a sustained community coalition’s original activities have been sustained. In the second case, some of a sustained community coalition’s original activities have been sustained. In the third case, none of a sustained community coalition’s original activities have been sustained.
All of a sustained community coalition’s original activities are sustained. For example, suppose an HCAP community coalition’s original goal was the improvement of coordination and integration of services. The coalition decided to implement an electronic medical record application at 15 different clinics in its service area. The HCAP funds were used to conduct several activities: to integrate clinic messaging standards, train providers in the county clinics about how to use the EMR, and purchase some of the needed hardware for the rollout. After the initial federal funding ended, the coalition was able to continue all of these activities because it found a suitable benefactor to continue the project. This is an example of a sustained coalition that sustained all of its original activities.
Some of a community coalition’s original activities are sustained. For example, suppose an HCAP community coalition’s original goal was the improvement of access to health care services for the uninsured. The coalition conducted a variety of activities to meet this goal when it was initially federally funded. First, the coalition expanded the network of providers in the community that would serve the uninsured at a reduced cost. Second, the coalition implemented patient navigation services to expand access to rural members of the community. Finally, the coalition disseminated health education materials throughout the community. After initial federal funding expired, the coalition has been sustained because it has an alliance of three or more organizations that continues to meet the original goal of improving access for the uninsured. However, after the initial federal funding ended, the coalition also had to cut several of its original activities because of budgetary constraints, and it now only focuses on expanding the network of providers that serve the uninsured. The local health department has continued the patient navigation services. However, the health education effort was not sustained. This is an example of a sustained coalition that has sustained some of its original activities.
None of a sustained community coalition’s original activities are sustained. For example, suppose an HCAP community coalition’s original goal was to increase access to primary care and prevention services in rural counties. The coalition’s original activities were related to health education and community outreach. Post initial federal funding, the coalition was sustained because it received a large grant from a foundation. As part of this grant, the coalition conducted a needs assessment involving focus groups with residents of rural counties. Findings from the focus groups indicated that transportation was the largest barrier to accessing primary care and preventive services in the coalition’s catchment area. In response to this new information, the HCAP coalition discontinued its original activities, and conducted new activities that address transportation needs in rural areas. This is an example of a sustained coalition that has sustained none of its original activities.
In addition to these examples, there may be many other variations (e.g., a partially sustained coalition that has sustained some/all of its activities, an expanded coalition that sustained none of its original activities but conducts several new activities, a coalition that was not sustained even though some or all of its activities live on in the community, etc.).
Regardless of whether the original activities of the coalition have continued, the coalition may take on new activities to reflect the economy, funding priorities, population demographics, evaluation results, or other factors.
Exhibit 5.2: Sustainability of the Community Coalition’s Activities
Exhibit 5.2 This exhibit displays the decision tree that will be used to define whether a coalition’s activities are sustained, expanded, partially sustained, or not sustained. The text following the exhibit describes each branch of the decision tree.