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State of Public Health

Infrastructure for Cross-Sector Collaboration: The State Health Leader Perspective

Carlin, Maggie MPH; Peterman, Emily MPH

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Journal of Public Health Management and Practice: July/August 2019 - Volume 25 - Issue 4 - p 405-407
doi: 10.1097/PHH.0000000000001038
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Cross-sector collaboration is a crucial mechanism for public health to address the social determinants of health and is recognized as a fundamental driver of community health improvement. As public health agencies seek to embrace this approach, relationship building across sectors is a key component of effective leadership. State health agencies regularly influence health determinants through partnerships and are well positioned to lead in this arena, but this leadership requires an infrastructure that supports cross-sector collaboration.

The field recognizes the need to foster collaboration across sectors, and there is growing consensus around investment in these partnerships. Inclusive engagement of communities and stakeholders in addressing health can advance equity and increase the impact of public resources. From the Robert Wood Johnson Foundation's Culture of Health Action Framework to the US Surgeon General's commitment to direct focus toward “better health through better partnerships,” the movement is well established.1–3

To undertake and maintain these collaborations, public health agencies must develop this capacity and integrate it within their operations. The Public Health National Center for Innovations identifies the ability to convene across agencies and partners as a needed foundational capability of health departments.4 In identifying pathways to health equity, the National Academies of Sciences, Engineering, and Medicine even proposed this primary role for public health agencies to “build internal capacity to effectively engage community development partners and to coordinate activities that address the social and economic determinants of health.”5(p420) As health agency leaders respond to these calls to action and build a collaboration infrastructure, they face both internal and external challenges.

In 2018, the Association of State and Territorial Health Officials spoke with a sample of state health leaders to better understand the infrastructure needed to cultivate cross-sector collaborations toward population health. This unique leadership perspective comprised state health officials, senior deputies, and health agency legislative liaisons to best represent those responsible for population health priority setting, policy decision making, and infrastructure development. The mixed-methods framework demonstrated consensus among state health leaders and identified themes regarding critical infrastructure needs, as well as environmental barriers to partnering effectively outside of public health.


State health leaders acknowledge the need to develop partnership capacity within their agencies and across the public health workforce. To do so requires adequate time and staff resources to engage other sectors. Predictably, leaders in the assessment most frequently described funding as a barrier to cross-sector collaboration; flexible funding is limited and resources are rarely allocated to facilitate these connections. One health official said, “Being able to have dedicated and focused people that are specifically charged with developing more cross-sectoral communications ... would be really valuable.”

Faced with these chronic funding challenges—and, in some jurisdictions, legislature-set full-time equivalent limits—expanding the workforce to build this is not a straightforward endeavor. Agency leaders must systematically support the existing workforce or rely upon short-term hires. They must also act within the confines of each jurisdiction's health agency governance structure when looking to increase resources across the state and local levels.

Workforce Development

Throughout the assessment, health officials and deputies emphasized pressing gaps in workforce capacity to strategically develop partnerships and undertake work that spans sectors and agencies. Foremost, agencies need targeted training to do this work. Cross-sector collaboration expertise was a frequent workforce gap raised by participating leaders, as well as a top training need identified through the Public Health Workforce Interests and Needs Survey. As of 2017, 38% of the workforce has training needs in this domain.6 One health official described the communication element of cross-sector expertise: “We need to translate some of our public health knowledge into plain language that others can understand.... Those concepts can all be explained in ways that are not either obscure or politically charged.”

State leaders also recognize an opportunity to improve collaboration infrastructure through intentional recruitment efforts. A public health workforce with diverse career backgrounds may be well-positioned to engage other sectors and stakeholders. Thoughtful and innovative recruitment strategies could establish a state public health workforce with expertise in population health, collaboration, and consensus building.

Systems Strategy

Leaders also highlight the need for enhanced data exchange strategies, requiring both adequate systems and informatics expertise. An infrastructure that is equipped to support comprehensive data collection, management, and sharing of population health information can drive increased collaboration. One state health official described how data sharing fosters cross-sector collaboration to address the social determinants of health: “Being able to share information across sectors is a way to facilitate the boundary spanning that needs to be done.”

Data sharing is a common collaborative activity for public health, and state health leaders describe that strengthened data exchange competencies would further their reach across sectors. Workforce development strategies focused on technical and nontechnical information-sharing approaches could position the public health sector to readily engage new and existing partners. Infrastructure and workforce that can support complex health information queries as well as programmatic knowledge exchange can enhance state-level collaboration to achieve population health.

Environmental Barriers

Outside their agencies, state health leaders contend with silos in state government and limited awareness of public health's role in addressing cross-sector issues. One health official described an expectation to “stay within [their] lane.” The challenge is exacerbated by competition among agencies and sectors. Governmental silos are reinforced as agencies compete for the same funding or public recognition.

These divisions among sectors also accentuate the lack of common language. Population health is still a relatively new concept for many sectors and other leaders, making it difficult to establish cross-sector support on common priorities. It is challenging for public health to maintain awareness of other agencies' activities and to initiate involvement in each other's work without a common understanding of the factors that determine health. One health official described population health as a mechanism for dialogue about how to improve the country's health but acknowledged that “not everybody's speaking that language yet.”

Building a Culture of Collaboration

State health leaders perceive cross-sector collaboration to be a critical strategy for addressing population health by aligning various perspectives and reducing governmental silos, and they see it as an important and regular component of their jobs. Themes from leader conversations indicate that the strongest cross-sector collaborations are supported by common priorities, formal agreements, and when there are individual champions for a specific population health priority within a state.

To build a culture of collaboration within a jurisdiction, state health leaders recommend operationalizing state priorities within public health infrastructure. According to state health leaders, finding common priorities with other sectors is the greatest supportive factor for collaboration. By strategically orienting population health goals to reflect the system's priorities, other sectors and leaders can more naturally align their objectives with those of public health. Intentionally developing partnerships that are mutually beneficial is crucial when building a strong culture of collaboration.

A Commitment to Advancing Collaboration

The 2018 assessment synthesized themes in state health leadership perspectives on the infrastructure needed for health agencies to reach across sectors. In addition to funding and staff resources to support crosscutting work, leaders need data systems to extend across agencies and a workforce that can confidently engage stakeholders and communities. This collaboration infrastructure could allow state health agencies to overcome sector differences to address the social determinants of health and leverage shared resources.

Those entities committed to supporting state health departments should thoughtfully direct resources and expertise to help agencies develop core capacity to collaborate on complex population health priorities. Efforts to build capacity in agencies, such as focused learning communities to establish and maintain partnerships, can help build this foundation. Technical assistance in innovative mechanisms to share resources and guidance on place-based initiatives to influence the social determinants of health is moving this work forward. Training in boundary-spanning leadership can instill this infrastructure at the top levels of state public health. Such efforts coalesce to “equip public health officials to mobilize ... cross-sector initiatives” to build healthy and resilient communities.7

State health leaders are actively engaging with other sectors to affect health in their jurisdictions and are looking inward to build the capacity to grow and sustain these relationships. Supporting these leadership efforts can help public health accomplish its imperative to engage all sectors in improving the population's health and well-being.


1. Robert Wood Johnson Foundation. Fostering cross-sector collaboration to improve well-being. Accessed April 12, 2019.
2. Towe VL, Leviton L, Chandra A, Sloan JC, Tait M, Orleans T. Cross-sector collaborations and partnerships: essential ingredients to help shape health and well-being. Health Aff. 2016;35(11):1964–1969.
3. Adams JM. The value of wellness. Public Health Rep. 2018;133(2):127–129.
4. The Public Health National Center for Innovation. FPHS planning guide: using foundational public health services to transform public health. Published January 2019. Accessed April 12, 2019.
5. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States. Partners in promoting health equity in communities. In: Baciu A, Negussie Y, Geller A, et al, eds. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2017:383–446. Accessed April 12, 2019.
6. de Beaumont Foundation. 2017 Public Health Workforce Interests and Needs Survey (PH WINS). Accessed April 12, 2019.
7. Association of State and Territorial Health Officials. 2019 President's challenge: building healthy and resilient communities. Accessed April 12, 2019.
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