Improving public health frequently requires collaboration between professional and community-based organisations. Health professionals and community activists typically bring different educational backgrounds, social experiences, and values to their collaboration. If handled well, these differences can lead to creative outcomes. If handled poorly, they can sabotage a programme’s potential.

From 2005 to 2007 I conducted an in-depth case study of one such collaboration – the relationship between the US Centers for Disease Control and Prevention (CDC) Global AIDS Program/India (GAP/I) and the Indian Network for People Living with HIV/AIDS (INP+) (1). I chose the GAP/I-INP+ partnership as the focus of study for five reasons. First, while estimates of HIV+ prevalence in India vary, AIDS is clearly a major public health problem. Second, by 2007 the GAP/I-INP+ partnership was in its fourth year, which provided a reasonable body of experience for analysis. Third, I believed there were reasons to see the GAP/I-INP+ relationship as a productive collaboration. Fourth, the fact that the CDC is a quintessentially scientific organisation, replete with MDs, PhDs and MPHs, while INP+ is a grassroots organisation for which the ticket of entry is HIV infection, not scientific background or even literacy, makes collaboration a challenging process, and potentially highlights factors important for successful professional-community collaborations. Finally, both partners welcomed the study and provided access to staff and materials.

The case study of the GAP/I-INP+ collaboration yielded three main lessons about values conflicts in professional-community collaborations.

Bridging the gap between cultures

Organisations, like individuals, are attached to their own values and cultures. GAP/I and INP+ would appear to represent an especially challenging partnership, given CDC’s strong scientific and technical orientation and INP+’s grassroots identity, combined with the fact that one was a 60-year-old United States governmental agency and the other a 10-year-old Indian community-based organisation.

Recognising the need to bridge the risky chasm between the two organisational cultures, GAP/I created a human bridge between the partners in the role it designed for Mr Jacob Varghese. Mr Varghese had been a CDC employee for five years. From the GAP/I perspective he was decidedly seen as “one of us.” But, at the same time, he had a strong background in, and commitment to, grassroots activities in India. From the INP+ perspective he was also seen as “one of us,” not in the employment sense, but in spirit, as I observed at a meeting between Mr Varghese and Mr KK Abraham (president of INP+) at the INP+ office on February 8, 2007. Mr Varghese was conveying GAP/I expectations for a time line and regular progress reports on an aspect of the collaboration. He conveyed the expectation clearly and firmly, but at the same time made informal comments that reaffirmed his commitment to INP+ and its objectives and to making the partnership work.

A bridging role of this kind calls for a definable set of personal skills, including flexibility, imagination, empathy, humor and thick skin. The role is as risky as it is important. At best, the bridging role acts as a pathway for constructive collaboration and mutual trust. At worst, the person in the bridging role can be caught in the middle of conflict between the partners and distrusted by both!

Mr Varghese told me that “since childhood on I have been a peacemaker – I inherited that from my father, who was always turned to if there was conflict in the family or among friends.”( interview, February 8, 2007) Although characteristics like these are necessary for success in a bridging role, they are not sufficient. In a study I did of how professional mental health organisations in the United States seek to build bridges to the community of people with mental illness, a person in a bridging role commented that “if an organization has designated only one person to communicate with consumers and the top management isn’t involved, the role is probably a waste of time and a setup for failure.” (2)

At GAP/I, top management was decidedly involved with the partnership building process from the start. Dr Dora Warren, the founding director of the GAP/I programme, described the perspective from which she had developed the programme as follows:

Progress and success is about having trusting relationships. Trusting relationships come partly from informal contact but also from really working together. When you start out with relatively little money as we did we had to add our direct work to what we provided. (interview, January 3, 2007)

Mr Varghese reported that Dr Warren conveyed the view that “you can’t do an HIV prevention and treatment programme without involving people living with HIV/AIDS – otherwise you won’t really know what the needs are and how to reach people at the grassroots.” In accord with Dr Warren’s orientation and values, GAP/I worked with INP+ in a manner similar to how some venture capitalists work with the start-up organisations they invest in. GAP/I invested a substantial portion of its funds in INP+, but like venture capitalists it also brought its staff and areas of expertise into the INP+ world and worked with INP+ in a collegial manner. The GAP/I approach was truly that of being a partner working with INP+, not simply a funder giving a grant to a recipient.

Calibrating an optimal level of tension for the partnership

Collaboration inevitably entails conflict. Effective partnerships – whether between individuals or organisations – require constructive conflict resolution procedures. An internal GAP/I memo in 2005 gave an example of non-constructive conflict: “The new manager joined [INP+] on June 13. Maybe due to the strained relationship, INP+ did not bother to inform GAP about this change, till we took the initiative to meet with the new recruit.” Whatever the motivation for not informing GAP/I about the new manager, and however accurate or inaccurate GAP/I’s interpretation of that motivation might be, this incident represented poor conflict resolution between the two partners.

Another GAP/I memo from 2005 stated that “GAP’s efforts and advice to improve INP+ service delivery and leadership were not received well by the project team.” In conversation the INP+ team told Mr Varghese that they felt that GAP/I was “pushing us too hard.” GAP/I feeling disappointed with the communications it received and INP+ feeling pushed too hard were two sides of the same conflict.

In their partnership, GAP/I and INP+, like a couple early in a marriage, struggled with the question of what they could reasonably expect from each other, how to handle conflict constructively, how much to pressure each other for change, and how best to apply that pressure. The skill with which these issues are handled can make or break relationships, both personal and organisational.

To be successful, partnerships must find an optimal zone of tension. Too little tension means expectations are too low and conflicts are not being faced. Too much tension leads to severed partnerships.

Dr Michael Friedman, associate director of GAP/I and leader of the Chennai-based office at the time, reported that managing the level of tension required consistent attention:

I struggle with the question of when it is best to push for more results and when it is best to go with what is happening. For example – CDC is a public health agency. We think about programme effectiveness and reaching large populations. INP+ is a community based organisation with direct service as one of its three goals. What are reasonable expectations for us to have about whether they are thinking about testing programme effectiveness and scaling services up to wider populations? There is no easy answer! (interview, February 7, 2007).

There is no magic formula for identifying and creating a zone of optimal tension. GAP/I, however, brought a keen awareness of the need to address the issue to its work with INP+ and recurrently reviewed the state of the partnership. It created a “human bridge” in Mr Varghese’s role to facilitate crucial feedback from INP+ – such as the feeling of being pushed too hard – and reflected on the implications, as by asking itself “Should we closely monitor the efficacy of the programme or give considerable leeway?” a question that it answered “yes/and”, not “either/or.”

I experienced the complexity of defining the optimal level of tension when I circulated an early version of the case study to the GAP/I staff. One reader found the draft “too sugar coated.” Another encouraged me to “tone it down.” The need for constant monitoring of the level of tension in a relationship and readiness to ratchet it up or down in accord with what is required is familiar in the literature and theory of counseling, but is not necessarily a skill brought to the relationships between organisations.

Patient and persistent support for capacity development

In areas of intense concern like the AIDS pandemic, professional organisations often seek community-based partners. Sometimes this is done because of values and beliefs and sometimes because of an externally-imposed requirement from government or funders. Partnerships between managerially sophisticated, technically advanced organisations and community-based entities are challenging for both parties. In addition to bridging the gap between professional and community cultures and careful calibration of an optimal zone of tension, the GAP/I-INP+ partnership demonstrated the importance of something so unglamorous that it could easily go unnoticed – patience, persistence and understanding.

The idea of a grassroots organisation like INP+ playing a significant role in the healthcare system was new in India. Despite passage of an ostensibly powerful Consumer Protection Act in 1986, the consumer movement in India was relatively weak. The Indian Medical Association brought suit to keep medicine out of the jurisdiction of the Act, but a 1995 decision by the Supreme Court of India (Indian Medical Association vs. VP Shantha) determined that healthcare should come under the purview of the Act. Longstanding cultural attitudes, however, have impeded development of an active role for consumers in shaping the system through which they receive their care. In this context, it is crucial for the professional organisation to cultivate the humble virtues of patience, persistence and understanding.

In the course of doing the research for the case study I came to see the GAP/I philosophy of building a trusting and collaborative partnership by working side by side with its community partner more as a moral perspective, than simply as a practical technique. The moral perspective corresponds to the well described concept of “Servant-Leadership” – an approach to leadership and institutions that envisions leading by serving those who are led. *

Interestingly, Chanakya anticipated the “Servant-Leadership” concept in the 4th century BC in the Arthashastra, when he wrote as follows about the proper moral outlook for kings: “In the happiness of his subjects lies his happiness; in their welfare his welfare; whatever pleases himself he shall not consider as good, but whatever pleases his subjects he shall consider as good.” (3)

Summary

GAP/I and INP+ represent markedly divergent cultures and therefore highlight the opportunities and strains associated with professional-community collaborations. I believe, however, that the factors that emerge from studying GAP/I-INP+ are not idiosyncratic and are relevant for other professional-community dyads. Every such partnership is likely to require some form of bridging mechanism to serve the same purposes as Mr Varghese’s role did. The task of creating a zone of optimal tension may be less familiar than the need to build bridges but it is no less important. Tension between partners with significantly different cultural backgrounds has tremendous potential for generating misunderstanding and distrust. Avoiding tension-laden issues is likely to entail significant cost, whether in the form of resentment, distrust, withdrawal, or settling for a lesser outcome than could be achieved. Finally, creating and sustaining the potential for constructive tension typically requires the humble virtues associated with servant-leadership: patience, persistence and understanding.

Note

* Information about Servant Leadership is available from the Greenleaf Center for Servant-Leadership: (http://www.greenleaf.org/).