SOLUTION: Resources, relationships, and systems thinking

Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=ccph20Critical Public HealthISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ccph20Resources, relationships, and systems thinkingshould inform the way community healthpromotion is fundedShane Kavanagh , Alan Shiell , Penelope Hawe & Kate GarveyTo cite this article: Shane Kavanagh , Alan Shiell , Penelope Hawe & Kate Garvey (2020):Resources, relationships, and systems thinking should inform the way community health promotionis funded, Critical Public Health, DOI: 10.1080/09581596.2020.1813255To link to this article: https://doi.org/10.1080/09581596.2020.1813255© 2020 The Author(s). Published by InformaUK Limited, trading as Taylor & FrancisGroup.Published online: 27 Aug 2020.Submit your article to this journalArticle views: 716View related articlesView Crossmark dataCOMMENTARYResources, relationships, and systems thinking should inform theway community health promotion is fundedShane Kavanagh a, Alan Shiellb, Penelope Hawec and Kate GarveydaSchool of Health and Social Development, Faculty of Health, Deakin University, Geelong, Australia; bDepartment ofPublic Health, La Trobe University, Melbourne, Australia; cMenzies Centre for Health Policy, Sydney School of PublicHealth, University of Sydney, Sydney, Australia; dManager, Partnership Development, Public Health Services,Tasmanian Department of Health, Hobart, Australia and Adjunct Associate Professor, Department of Public Health,La Trobe University, Melbourne, AustraliaABSTRACTPublic health agencies tasked with improving the health of communities arepoorly supported by many ‘business-as-usual’ funding practices. It is commonplace to call for more funding for health promotion, but additionalfunding could do more harm than good if, at the same time, we do notcritically examine the micro-processes that lead to health enablement –micro-processes that are instigated or amplified by funding. We are currentlyengaged in a university-and-policy research partnership to identify howfunding mechanisms may better serve the practice of community-basedhealth promotion. We propose three primary considerations to inform theway funds are used to enable community-based health promotion. The first isa broader understanding and legitimising of the ‘soft infrastructure’ orresources required to enhance a community’s capacity for change.The second is recognition of social relationships as key to increasing theavailability and management of resources within communities. The thirdconsideration understands communities to be complex systems and arguesthat funding models are needed to support the dynamic evolution of thesesystems. By neglecting these considerations, current funding practices mayinadvertently privilege communities with pre-existing capacity for change,potentially perpetuating inequalities in health. To begin to address theseissues, aspects of funding processes (e.g., stability, guidance, evaluation, andfeedback requirements) could be designed to better support the flourishingof community practice. Above all, funders must recognise that they are actorsin the health system and they, like other actors, should be reflexive andaccountable for their actions.ARTICLE HISTORYReceived 15 May 2020Accepted 10 August 2020KEYWORDSFunding models; resources;systems thinking; healthpromotion; practiceIntroductionIn the UK, 150 disadvantaged communities have been given £1 million each by the National LotteryCommunity Fund to improve their health and well-being. But the Big Local project is not just about (whatmight seem like) an eye-watering amount of money. Of interest is that residents themselves have beenenabled to make the decisions about how best to use the funds (Local trust, n.d.). Both factors might beimportant in bringing about success (Reynolds et al., 2015). While the evaluation of Big Local continues,the landmark experiment challenges those of us outside, and researchers everywhere, to think criticallyabout funding as a lever for change and the opportunities to increase its reach and value. Funding alonemay prove insufficient to bring about whole community improvement. A critical combination ofCONTACT Alan Shiell A.Shiell@latrobe.edu.auCRITICAL PUBLIC HEALTHhttps://doi.org/10.1080/09581596.2020.1813255© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided theoriginal work is properly cited, and is not altered, transformed, or built upon in any way.conditions, sequences, and processes may need to be present to ensure that money acts as an assetrather than a burden.We are currently engaged in a collaborative university-and-policy research partnership with a statehealth department in Australia. We are using reflection-and-action methods with funding decisionmakers, seeking to improve the way funding mechanisms serve the practice of community-based healthpromotion. Our aim is to critically analyse how funding interacts or ‘couples’ with context (Hawe et al.,2009). This involves interrogating the pre-existing and co-incident factors that might be useful inmaximising gains from funding, and in ensuring benefits are distributed equitably. By funding, wemean the intentional transfer of money from one agency (the appropriating agency) to another (theprovider agency) for the purposes of promoting health. This transfer could be from one level ofgovernment to another, from government to non-government organisations, or from philanthropicsources to government or non-government entities. The task of funding community-based interventionsis not simple. Even seemingly straightforward health-enhancing activities, such as efforts to increasevaccination rates, depend for their effectiveness on levels of literacy, scientific knowledge, and trust inpublic institutions (European Centre for Disease Prevention and Control, 2012). The task of mobilisingcommunity engagement and support to tackle contemporary health challenges such as drug and alcoholmisuse, domestic violence, or obesity may be far more challenging.Internationally, health promotion is funded in multiple ways from a myriad of sources. Each fundinginitiative can be associated with different time frames, objectives, and conditions attached to theallocation of funds (Institute of Medicine, 2012; World Health Organization, 2007). Funding is rarely stableor predictable over time and even government funding can vary substantially from year to year, oftenwith adverse consequences for the public’s health (Institute of Medicine, 2012). New funding initiativesare often short-lived and sporadic, with an emphasis on small-scale projects to meet specific programmatic objectives (Lovell et al., 2015). Furthermore, poorly considered funding schemes can often undo thebeneficial effects of past investment (Baum et al., 2016). Funding can even worsen health inequalities byinadvertently privileging communities with the pre-existing capacity to find, secure, and utilise newsources of support (Institute of Medicine, 2012). Uncertainty and variability in funding are common(Roussy et al., 2019; Witter et al, 2007). Many funding schemes require a focus on innovation, which canencourage time-sapping repackaging of existing interventions rather than rational, long-term planningfor the sustainability or spread of good practices (Hawe, 2015).For almost 30 years, health promotion scholars have been exploring how best to sustain effectivepublic health programs following the end of pilot funding – assuming that funding is, of necessity,short-lived (see, for example, Bracht et al. (1994) and Steckler et al (1989)). Lack of sustained fundingmight still be the current political reality of health promotion. It does not have to be accepted. Butconcern with how much should be spent on promoting the public’s health is possibly overshadowingconsideration of the variety of processes for health improvement that funding is in a unique positionto enable (Leider et al., 2018). Once made visible these processes might be scripted better andadapted so that any amount of funds (eye-watering amounts or not) are used well.This is a discussion paper, based on insights from the early stages of our work. We outline threeprimary considerations for funding health promotion. The first consideration is the need fora broader appreciation of the range of resources required to enhance a community’s capacity forchange. The second involves recognising social processes and social relationships as the basis for thegeneration, diffusion, and optimal management of resources. The third requires an understandingthat communities are complex systems. Taken together, these three factors point to the need fora better understanding of how external funding, and the mechanisms used to allocate and manageit, affects the ability of community organisations and agencies charged with promoting health tocarry out their jobs. We suggest that a complex systems approach, together with a focus on criticalresources and social relationships, provides the basis for a (formal) funding model for healthpromotion better suited to dealing with community health challenges. In the final section of thepaper, we consider implications for funding strategy and policy. A funding model is the logic andstrategy of using funds to build health improvement. We distinguish this from a financing model,2 S. KAVANAGH ET AL.which we take to mean the strategy to build reliable revenue sources (e.g., through a sales tax onsugar or tobacco).A deeper understanding of resourcesResources are the raw materials that provide the basis for communities and individuals to functioneffectively and to engage in processes of change. Without the necessary resources to supportprocesses of change and sustain new patterns of functioning communities cannot evolve andadapt, and external efforts to improve the health of communities are likely to fail (Trickett, 2009).External funding often focuses on the acquisition of the material and human resources needed todeliver programs or conduct other health-promoting activities. These are vital for communities,particularly disadvantaged communities (Marmot et al., 2010). But these resource types rarely reflectthe full needs of communities to undertake change. A wider view of resources is required.Broadly conceived, resources are all of the things that communities need to function effectively andto undertake change (Center for Community Health Development, 2019; Trickett et al., 1985). Inaddition to the usual factors of production (labour and capital), this view recognises the importanceof social, relational, moral, cognitive, and emotional resources (Edwards et al., 2004; Foa et al., 2012;Hobfoll et al., 1993). These additional resources are an extension of Duhl’s (1986) notion of ‘softinfrastructure’, without which a community’s resilience is significantly diminished. Soft infrastructuretakes many forms: it includes hope and trust (Moore et al., 2017); narratives of identity and world-view(Rappaport, 1995); safe spaces (Campbell et al., 2007); self-efficacy (Bandura, 2004); governance (Evanset al., 2015); and cultural symbols (Bourdieu et al., 1977). Resources such as these are crucial fordevelopment and improvement in communities. Culture and identity provide the basis for marginalised groups to build capacity and to sustain and participate in successful programs (Morley, 2015;Stewart, 2005). Safe spaces allow community members to engage with difficult issues and workcollectively to overcome obstacles and translate new knowledge into action (Campbell et al., 2007).Individual and community narratives motivate and sustain action for change (Rappaport, 1995), whiletrust is a precondition for engaging in collective processes (Kawachi et al., 2014; Ostrom, 2000).Such ‘soft’ resources are no less essential than the material resources usually associated with fundinginitiatives, but they are characteristically different. One cannot buy the acquisition of hope or trust orcollaborative capacity in the same way that one can pay for the acquisition of staff. Instead, wherefunding is required, it must be provided in ways that support the local capacity-building actions of frontline staff and enhance (and not displace) the processes through which hope and trust et cetera aregenerated. This requires awareness on the part of the funding bodies of geographic and social differencesin pre-existing levels of soft infrastructure and community readiness for change, as well as fundingmechanisms that are sensitive to the different demands such variation in readiness places on front linehealth promotion practitioners. Such awareness and sensitivity would enable funding initiatives to bebetter aligned with local efforts to develop or maintain soft infrastructure and reduce the likelihood thatexternal funds divert attention and resources away from well-founded local priorities.The role of social relationshipsAgency arises, collectively, through dialogue and engagement in the context of social relationships(Campbell, 2014; Freire, 2005; Vaughan, 2014). Social relationships are a special class of resources inprocesses of community change (Edwards et al., 2004; Stewart, 2005; Valente, 2012; Valente et al.,2015). Within communities, social relationships take multiple forms including informal social networks, formal and informal groups, and organisations. The nature of the ties that connect (or fail toconnect) individuals within each of these network forms will also vary. The resulting structures, asreflected in the patterns created by the ties that exist among network members, play an importantrole in processes of change by impacting on resource availability and management.CRITICAL PUBLIC HEALTH 3Network structures impact on the availability and value of resources in communities in two ways(Borgatti et al., 2011). First, the ties among community members act as conduits or pipelines thatinfluence the dissemination of resources throughout the community. Communities with diversenetworks are likely to have a greater propensity for change over time because of their relativeopenness to new ideas and knowledge (Granovetter, 1973; Griffith et al., 2008; Monge et al., 2003). Incontrast, communities with denser, more closed connections are better able to coordinate the use ofresources, potentially reducing duplication and waste (Nowell, 2009). In both cases, the value of anyresource travelling through the network is enhanced if it moves through established relationships orthrough key individuals in the network because of the additional meaning and legitimacy thisconveys to subsequent recipients (Hawe et al., 2009; Valente, 2017).Secondly, the community’s ability to secure and exercise power and control over resources(whether they are provided externally or generated from within) is a function of the bonds thatexist between its members. This enables some groups to work collaboratively in their common interestto redress or reinforce power differences. Borgatti et al. (2011) refer to unionisation among employeesto illustrate this point, but one sees it also in Ostrom’s (1990) work examining how social relationshipsprovide the basis for effective management of collective resources and in the discussion by Edwardset al. (2004) on how social relationships help to convert individual resources into collective resources tosustain collective action. Social bonds provide the basis for the generation of much of the softinfrastructure within communities (Freire, 2005; Kawachi et al., 2014; Stewart, 2005).However, collaborative bonds can lead to differential outcomes across a network. For example,network power can be used to usurp the aims of externally funded health-promotion initiatives, andresources may be mismanaged if local decision-making and governance capacities are weak or nonexistent. To complicate matters further, networks that encourage or support unhealthy behavioursmay also provide positive benefits to network members such as social support, recognition, andstatus (Dolan, 2014; Flores et al., 2013; Lohan, 2007). A central focus of community development andcapacity building, therefore, becomes the creation of relationships, where links are absent orotherwise not achieving community needs (Held et al., 2020). For these issues to be detected andmanaged, health workers need funding to be constantly ‘on the ground’. This work can be funded asa responsibility of a health promotion practitioner (Crisp et al., 2000).These dynamics also illustrate that a more diverse and sophisticated notion of networks isneeded so that funding processes look beyond the current emphasis simply on ‘partnerships’ andgaining letters of support. Indeed, the ability to muster quick partnerships and letters of supporthas been criticised as evidence that those who need funds are least likely to get them (Mowbray,2005).Communities as complex systemsThe third consideration of funding processes is to recognise that communities are complex adaptivesystems. Resources and relationships are both part of systems thinking. In the Foreword to‘Governance for health in the 21st century’, the World Health Organization’s Regional Director forEurope, Dr Zsuzsanna Jakab, writes that: ‘Pathways to good and poor health can be nonlinear andhard to predict, and health is increasingly understood as a product of complex, dynamic relationships among distinct types of determinants’ (Jakab, 2012, p.vi). We are unlikely therefore to designeffective public health interventions for contemporary problems or implement them successfullywith reductionist thinking and simple ‘cause and effect’ conceptualisations of change (Fink et al.,2017; Heitman, 2017). Our intervention design and delivery strategies need to be cognisant of thefact that communities are complex, dynamic systems (Hawe et al., 2009; Matheson et al., 2018; Shiellet al., 2008). It follows that the funding mechanisms we adopt to support those strategies also needto be cognisant of the special demands made by systems thinking.Space precludes an extensive discussion of the full insights offered by systems thinking. However,two of the critical features in Jakab’s succinct statement about the pathways to good health can be4 S. KAVANAGH ET AL.used to illustrate the funding implications of systems thinking for public health practice. The first ofthese is that health improvement is non-linear, which just means that there is not alwaysa proportionate dose-response relationship between intervention intensity and outcome. Instead,many health improvement efforts demonstrate threshold effects or phase transitions or, in morepopular language, tipping points (Gladwell, 2002). Such quantum changes are seen at both theindividual level with lifestyle behavioural change regarding tobacco use for example (Resnicow et al.,2008; Resnicow et al., 2006), and at the policy level as illustrated by the introduction of gun controllaws in Australia (Chapman, 2013; Peters, 2013). In such cases, the outcome of interest appearsresistant to any effort to improve it until some critical combination of factors comes together anda transformative change occurs. Individuals suddenly quit smoking, and countries adopt gun controllegislation that previously they had resolutely opposed.In these circumstances, it is tempting to attribute the desired change in behaviour or policy to theevents or actions that immediately preceded the change. But such proximal reasoning ignores theprior actions and advocacy that had diligently prepared the ground. Smokers who ‘just decide’ tostop smoking overlook their past failed quit attempts and their years of exposure to anti-smokingmessaging. The Australian gun laws were enacted in the wake of the Port Arthur massacre butfollowed many years of research and sophisticated advocacy by public health experts (Peters, 2013).Jakab’s second observation is that health improvement occurs in a dynamic, ever-changingcontext. Hence, it does not make sense to think about ‘solving’ public health problems. Rather,public health professionals seek to improve situations whilst remaining ever diligent to the certaintythat threats to population health will recur. One sees this most obviously in the emergence of newbiological threats, such as SARS-CoV-2, and the re-emergence of old ones such as tuberculosis. Butthe same underlying processes of adaptation and re-emergence happen more generally: in thecyclical effects of the economy and the recurrent imposition of austerity measures (Stuckler et al.,2017), in the responses of the tobacco industry to public health policies (World Health Organization,2009), in the efforts of the gun lobby to pull back gun control legislation, and with lobbyists moregenerally looking to repeal or resist public health regulation or legislation where it is contradictory towell-funded private interests (Cave et al., 2014; Rennie, 2018).Practitioners spend time nurturing and developing the soft infrastructure that enablesa community’s resilience to such recurring issues. They often focus on the most urgent needs andin doing so create in-roads for the main (funding-led) activity; they work in and around existingnetworks to mobilise resources to build bridges where important connections are absent and theyremain alert to the emergence of counterforces. This occurs even while they are funded to addressconventional health problems, such as obesity prevention (Groen et al., 2020).This type of practice does not rule out the use of program logic models, but it does mean that thesemodels need to be frequently adjusted to remain relevant in the face of dynamic change. For example,interim milestones should refer less to the achievement of pre-determined intermediate outcomes andmore to the iterative processes of exploring what works in context (Rogers, 2008). Under thesecircumstances, funding mechanisms which reward rash promises about health improvement, or relyon the achievement of predictable quarter-by-quarter targets are deluded. Researchers in internationalhealth and development are especially conscious of many of these issues. They observe that funderstend to create overly structured processes which preference ‘siloed’ actions, shying away from makingthe complex changes to the social and economic fabric that are needed (Panter-Brick et al., 2014).What this thinking offers funding strategy and policyWhile there is a well-developed literature on community readiness assessment and technicalcapacity building: essentially preparing communities to take on the responsibility of funds forimplementing particular evidence-based programs (Chinman et al., 2016), our interest is more inthe development and nurturing of generic pre-conditions and evolving change processes that affectthe impact of any funding initiative. More particularly, our interest is in the ongoing adjustment ofCRITICAL PUBLIC HEALTH 5funding processes to better support health promotion practice, rather than just the (pre) readying ofcommunities. While our work is still in progress, we can outline some areas of investigation we arepursuing in response to the ideas laid out in this paper.First, the resources that a community has and the resources that a project proposal aims todevelop can be listed and described, and proposers might be asked to consider critical resourcecombinations that need to be in place to maximise impact. Investigative work of this kind could befunded. Beyond the conventional understanding of skills and materials, extra attention would needto be given up front to the ‘soft infrastructure’, thus encouraging awareness of it at a communitylevel. For example, a creative arts project, such as the production of a play, may be put forward forevent funding. Typically, the project might be posed as a way to reduce anxiety and develop thetalents and abilities of youth. This would be stated along with the estimated audience reach.However, with encouragement, the play might also be understood as a way to seek out, understand,and build the (additional) resource of narrative identity (Rappaport, 1995). Thus, extra advice andincentive in the funding guidelines might help to identify, legitimise, and strengthen resources thatmight be otherwise overlooked or taken-for-granted.From a social network and relationship perspective, funding could consider not just partnershipsand support as mentioned before, but how the opportunity and advantages provided by fundingwould be distributed. In health promotion, it is repeatedly observed that those who need theactivities least gravitate to them the most, and those agencies with resources attract resources(Wharf-Higgins et al., 2008). So, the opportunity could be taken to ask project-proposers to considerhow these possibilities would be recognised and overcome. Respondent-driven sampling methods(originally designed and used to reach marginal populations like drug users) could be adopted toreach people and organisations on the network periphery (Heckathorn, 1997). A social networkperspective would also call for reporting on not just the first-order changes brought about by theinjection of funds (among those reached by the program or activity) but some account could berequired of the second and third-order changes. That is, how those reached by the interventionsubsequently used the resources it created (e.g., knowledge, ideas, trust) in their own networks, andso on. The focus should be on demonstrating how resources are transformed through networks(Hawe et al., 2009), thus evaluating the on-the-ground time and skill committed by practitioners tocoach processes of network change.Systems thinking is already influencing how health promotion is practised and evaluated(Allender et al., 2019; Joyce et al., 2018; Matheson et al., 2018; Rosas, 2017), but it has not largelyaltered how health promotion is funded. The way funders recognise and appraise the value of effortsin the field is rarely any different from the process applied to conventional health promotion. Effortsto fund whole of community, systems-thinking health promotion (including ‘signature’ strategiessuch as system mapping and ‘safe to fail’ experimentation) may be deemed too risky by stategovernments because of the unpredictability of outcomes and its inability to fit with conventionalaccountability monitoring. It does not help that systems thinking has become somewhat of a mantra:the key precepts are repeated among the followers, but the practical consequences of it remainunconvincing to many health policymakers (Wutzke et al., 2016). This scepticism is the mainchallenge.The first response must be to build reliable information on what is being explored, tried, andachieved, and the learning and logic that comes from that (Rogers, 2008). It is an unfortunate ironythat the ‘era’ of systems thinking is overlapping with the current era of problem-focused targetedfunding. The building of soft infrastructure in communities is likely being under-reported, underrecorded, and undervalued because few funding authorities are paying to hear about it. Systemthinking practice employed within targeted or siloed problem-defined funding is legitimate andreported (Bagnall et al., 2019). But the point is, practitioners whose focus is relationship and/or equityoriented are often drawn to problems in communities that are more immediate than those that aretypically identified as state or national priorities (Groen et al., 2020) and their story is not being told.To gain insight into how the dynamic-evolution of community systems could unfold, funders need to6 S. KAVANAGH ET AL.devise more free-form ways of reporting process, with indicators that are relevant to practice andmore neutral to ‘what’ was paid for or intended.A clear conclusion from our reflections to date is that funders would be wise to provide salaries forconstant ‘on-the-ground’ workers whose job it is to connect agencies, build relationships, identifyassets, and align and coordinate activity. That is, someone whose job it is to attend to the building andmanagement of soft infrastructure and the coaching and reporting on system change. But there areother implications to explore for the future. These include ideal funding amounts, sequencing, timing,time frames, the role of field reports, and criteria for interpreting success and failure, especially in theshort-term. A particular challenge will be the ability to recognise progress-in-the-making becausecomplex adaptive system change is probabilistic, rather than deterministic. That is, a practitioner’sresponsibility is less about giving direction (and making predictions) and more about encouragingdifferent parts of the system to interact so as to maximise the chance that the path forward will befound among new resource and relationship combinations (Resnicow et al., 2008). Funders are notnecessarily antithetical to these ideas. Indeed, the most innovative among them are attempting toorient their processes towards ‘learning partnerships’ with communities, where the discovery ofpractice-based knowledge is a shared priority of both funders and grantee (Marsh et al., 2008).Some lessons for funding communities may be analogous to those derived from the study of cashtransfers to individuals to address the social determinants of health where there is growing literatureon how context-levels factors inhibit, enable, or optimise the effect of money per se (Akresh et al.,2016; Handa et al., 2014; Owusu-Addo et al., 2019). In other words, funders of community healthneed to orchestrate, scrutinise, and constantly revise how they bring about change with a wider andmore context-sensitive appreciation of what can be achieved, when and how.ConclusionFunders are actors in the health system and should be reflexive and accountable for their actions.The amount of funds, the frequency, and the conditions and evaluation requirements stipulated byfunders for public health interventions instigate micro-processes of community response that mightprivilege some outcomes over others. We ask for more investigation and critical analysis of fundingprocesses as levers for change in local community systems.Disclosure statementThe authors report no conflict of interest.FundingThis work was supported in part by the Australian Prevention Partnership Centre through the National Health andMedical Research Council grant GNT 9100001ORCIDShane Kavanagh http://orcid.org/0000-0003-0961-7659ReferencesAkresh, R., de Walque, D., & Kazianga, H. (2016). Evidence from a randomized evaluation of the household welfare impactsof conditional and unconditional cash transfers given to mothers or fathers. World Bank. http://documents.worldbank.org/curated/en/944741467047531083/pdf/WPS7730.pdfAllender, S., Bolton, K. A., Fraser, P., Lowe, J., & Hovmand, P. (2019). Translating systems thinking into practice forcommunity action on childhood obesity. 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