Engaging Communities to Reduce Health Inequalities: Why Partnership?

Anna Matheson, ¹ PhD candidate
Philippa Howden-Chapman, Associate Professor ²
Kevin Dew, Senior Lecturer
Department of Public Health
Wellington School of Medicine and Health Sciences
University of Otago

Abstract

The current policy trend to have the reduction of health inequalities as a desired outcome indicates a serious attempt to deal with the complexity of social interactions. In New Zealand in recent years the landscape for government–community relationships has also changed significantly. The prescriptive contracting environment of the 1990s has been replaced, in many policy areas, by the rhetoric of partnership. In theory, partnership seems to offer policy makers a way to respond to complexity in a flexible manner, and is perhaps a way to cope with levels of uncertainty in implementing policy. This paper discusses the background to the rise of the concept and the practice of partnership in New Zealand and gives examples of how it is currently being used. This is followed by a discussion of common themes identified from an extensive literature review. These themes are: the connection between partnership and participation; the impact of trust and power in relationships; the importance of local knowledge to understanding the local context; and understanding the capacity of communities to change. The paper concludes with a discussion of these themes and their relevance within both community and government settings. It recommends that to do justice to ideas of working in partnership to address complex social problems, such as reducing health inequalities, the theory and practice need to be considered far more carefully than they have been so far.

Introduction

Reducing health inequalities as a desired outcome for health and social policy interventions in New Zealand is a relatively recent phenomenon. It has emerged alongside other policy area definers such as “intersectoral action” and “whole of government” approaches, which also take a connected and longer-term approach to problem solving. This growing concern to reduce health inequalities brings with it some underlying assumptions, including the social environment is an influential factor in determining health outcomes; society is interrelated and connected; and solutions to reduce health inequalities need to be systemic. The parallel rise in popularity and use of partnership approaches (defined or otherwise) to achieve social goals reflects this new emphasis on the importance of social connections and relationships.

This paper outlines developments in the use of the term “partnership”, particularly in relation to social goals such as reducing health inequalities. After a brief introduction to health inequalities it describes the background to the rise of partnership in New Zealand and gives examples of how it is currently being used. This is followed by a discussion of common themes relevant to partnership that have been identified based on an extensive literature review. The paper concludes with some discussion on these themes and their application for decision and policy makers.

The impact of the social environment on health can be seen in the extremely powerful and enduring relationship between health and social and economic inequalities (Dew and Kirkman 2002) . Considerable research effort has gone into describing health inequalities, understanding their causes and trialling interventions to reduce them (Ajwani et al. 2003, Mackenbach and Bakker 2002) . Both nationally and internationally, reducing inequalities has become a desired outcome for government policy, not least in the area of health.

Our understanding of health inequalities has its roots in the discipline of epidemiology, which has appeared over the last century in a number of guises (Berkman 2004) . Epidemiology measures the distribution of disease, with early studies finding social variations in the incidence of many diseases. More recently, social epidemiology has taken this further by exploring the distributions and relationships of social characteristics and disease. The picture created by social epidemiology graphically illustrates the impact the social environment can have on people and their health. Characteristics such as socio-economic status, ethnicity, employment status and housing tenure, for example, have all shown relationships to health outcomes (Ajwani et al. 2003, Berkman and Kawachi 2000, Howden-Chapman and Tobias 2000).

Perhaps the earliest significant effort to influence governments regarding the necessity to look seriously at health inequalities was the Black Report. It was presented to the United Kingdom Government in 1980 and highlighted the statistical evidence of the relationship between the social world and disease. As a consequence, equity in health and a reduction in health inequalities were incorporated as targets for the World Health Organisation to achieve by the year 2000 (Howden-Chapman and Tobias 2000).

In New Zealand , since the Labour-led coalition government came into power in 1999 the landscape of government–community relationships has also significantly changed. The arms-length, outputs-focused, prescriptive contracting environment of the 1990s has been replaced, in many policy areas, by the rhetoric of partnership as a means of delivering social goals. The idea that communities themselves are integral to finding solutions to complex social issues has become popular, particularly when dealing with social and health inequalities, and also that if government “partners” with communities the solution will be more valid, long-lasting and meet local need. A number of key government documents have been developed that emphasise the quality of the relationships with non-governmental organisations (NGOs) and community organisations. Although the term “partnership” is only sometimes explicitly used, the words and ideas such as trust, respect and reciprocation, written in these documents, denote a particular set of values attributable to these relationships. (Department of Prime Minister and Cabinet 2001, NZAID 2003, Treasury 2003).

The New Oxford Dictionary of English defines partnership as “an association of two or more people as partners” (Oxford University Press 2001) , and when examples are provided they are in the context of business relationships, with the purpose being to manage profit and loss. A definition of partnership where its purpose is social intervention is more complicated to define. Partnership in this instance is either not defined or described in terms of the methods used for the intervention. An example of the latter can be seen in “community-based participatory” research, where partnership approaches aim to include the community context and community voice in the generation of knowledge. Doing this successfully requires such things as trusting relationships, longer time frames, mixed methods of inquiry and the sharing of costs and benefits (Israel et al. 1998, Minkler and Wallerstein 2003).

The language of partnership is used widely in the public and community sectors, although it is clear that agreed definitions of partnership are hard to come by. Still, the use of the term “partnership” in delivering social interventions has become relatively commonplace in the last few years. A Ministry of Social Policy ³ (2000) review of these partnership models highlights the difficulty in determining whether “partnership models” are effective in attaining social goals:

The literature does not answer the question of whether partnership models offer any benefits over other models in terms of achievement of welfare goals. (Ministry of Social Policy 2000 :3)

There seem to be three main reasons for the difficulty in answering this question. The first is the lack of theory around why a “partnership” relationship might be more appropriate in certain circumstances. Secondly, there is a lopsided concentration on communities and community organisations in discussions on partnership in a social intervention context; often the part played by government organisations or other institutions is left unanalysed. Thirdly, because “partnership” is usually used in situations where problems are complex and it is difficult to “prove” outcomes in a more traditional sense, it is hard to find measurable benefits of the partnership.

Partnership in New Zealand

A number of factors have influenced the current use of the term “partnership” in New Zealand . These include partnership as represented by the Treaty of Waitangi; the historical New Zealand government relationship with the NGO/community sector; international trends stemming from ideas such as social inclusion, social exclusion, social capital and a greater acknowledgement of the “third sector”; and the growing use of inclusive methods for social change, such as community development.

Unique to New Zealand is the specific use of “partnership” in relation to Te Tiriti o Waitangi (the Treaty of Waitangi). The Royal Commission of Social Policy (1988) summarised the three Treaty principles as participation, protection and partnership. The Court of Appeal’s decision on the disposal of Crown land in 1987 also established a principle of partnership, which required the Crown to consult and act in good faith. This legal opinion underpinned a growing interest in partnership as part of community development. Yet many Māori criticise this use of partnership as inappropriate to a Treaty analysis. Partnership in a legal sense is derived from contract law and seen in examples of company partnerships, where partners may be unequal. Treaty law speaks more appropriately of relationships (Jackson 1998).

In the context of improving social outcomes more generally, within the public sector the concepts of social capital or social exclusion are used as the basis for partnerships, because partnerships are seen as an opportunity for building greater social cohesion (Department of Internal Affairs et al. 2002, Hong 2001) . As a policy idea this was most recently influenced by Coleman (1990) and Putnam (1995) , whose research identified communities with strong social capital – that is, communities with strong social organisations and networks – as benefiting socially and economically through increasing social cohesion and trust. There has also been the increasing popularity in the policy arena of community development approaches that build on the importance of social cohesion.

This increasing activity around the government taking the quality of relationships seriously has been spurred by growing international interest and acknowledgement of the NGO/community or “third” sector. Encapsulated by the “third way” championed by the Blair Government in the United Kingdom , this has led to a more explicit focus on social inclusion, exclusion and inequality. This perspective of viewing the “third sector” as a serious societal grouping has influenced and led to a change in thinking in New Zealand around the role and nature of relationships (Baxter 2002, Craig and Larner 2002).

This direction has been compounded by the historical influence of government previously having a highly prescriptive contracting environment that seemed to have no room for more complex outcomes. Indeed, the public sector reforms of the late 1980s, and early 1990s for health and welfare, which arguably trimmed and focused New Zealand’s growing and cumbersome public sector, led to a number of changes. One change was the introduction of performance-based management centred on highly specified service outputs, as opposed to outcomes. Outcomes, it was argued in Public Choice Theory (Boston et al. 1999) , were too complex to have identifiable causation and this left too many doors open for opportunism on the part of public servants and public sector interest groups. The separation of policy advice from implementation in policy was in response to the threat of provider capture. ⁴ The New Zealand public sector took a particularly ideological approach to this threat with a separation of policy and operational function that was more formal and legally based than in comparable countries (Howden-Chapman 1993).

This has had major implications for the delivery of social policies in New Zealand . Because the signing of formal competitive contracts was given priority, the importance of relational contracting and the policy implementation process were undervalued. The emphasis on the top end of the contracting process left little room for flexibility and uncertainty in the delivery of those policy goals. This has changed in recent years, with a focus in over-arching government documents on the quality of the relationships with community organisations. Often these documents make reference to partnership but leave its meaning or purpose unclarified (Department of Prime Minister and Cabinet 2001, NZAID 2003, Treasury 2003).

There are many current government initiatives that focus on collaborative relationships, some of which are described explicitly as partnerships. In 2000 the Government established a Community and Voluntary Sector Working Party. It has produced two reports summarising a community view of government–community relations that strongly recommends the need for government to be more responsive to communities (Community and Voluntary Sector Working Party 2001, Community–Government Relationship Steering Group 2002) . The Department of Internal Affairs et al. in their Framework for Developing Sustainable Communities (2002) highlighted the relevance of engaging in partnerships to give communities greater voice and control. Housing New Zealand Corporation (HNZC) has begun a partnership programme of “community renewal” interventions with people living and working within particular areas to promote safe, healthy communities. HNZC has also instituted a partnership programme involving community groups, iwi and Māori and Pacific organisations, and local government. These initiatives involve targeted interventions to eliminate substandard housing in an attempt to address housing need by incorporating input and ownership from the community. ⁵ 

Two health sector initiatives underway are the Intersectoral Community Action for Health (ICAH) projects, which take a cross-sectoral approach to improving health in geographically defined areas of need, ⁶ and the newly created primary health organisations (PHOs), which aim to integrate primary health care services to provide more appropriate and accessible primary health care (Ministry of Health 2001) . One of the purposes of this integration is to enable different provider organisations to work together instead of in competition.

The social and health sectors are not alone in emphasising relationships. The Ministry for Economic Development and Industry New Zealand ⁷ operate a Regional Partnerships Programme aimed at improving economic opportunity in particular geographic areas. Local governments around the country have also embraced the idea of partnership with their communities. For example, the Porirua City Council aims “to build a partnership between the Porirua community and the Council” (Drage 2002) and, in turn, with central government agencies. The new Local Government Act 2003 moves to strengthen the bond between local government and communities through the requirement for increased democracy and participation, although some have noted it falls short of requiring formal partnerships (Drage 2002, Lynch 2002) . In practice, however, some local bodies have moved to form partnerships (or at least formal relationships) with local iwi.

This shift to an emphasis on relationships can also be observed within the research environment, where funding criteria have changed in recent years, moving to a concentration on research collaborations, on disseminating research findings widely and on longer time frames for research outputs. This change has fostered research undertaken cross-sectorally and with communities. For example, the Strengthening Communities through Local Partnerships project, jointly undertaken by the Waitakere City Council and the University of Auckland , has been funded by the Foundation for Research, Science and Technology to explore the concept and practicalities of local partnerships. ⁸ Also, funded by a substantial Health Research Council grant, He Kainga Oranga / Housing and Health Research Programme, has carried out much of its research working in collaboration with community and other organisations to better understand housing issues (Baker et al. 2004, Howden-Chapman et al. 2004).

Underpinning this renewed focus on relationships are theories of social change, in particular the “third way” as espoused by Giddens (1998) , where society is viewed pluralistically and subjectivity is acknowledged. This is perhaps a popular shift in understanding society, with partnership a policy response to this understanding of the complexity and connected nature of the social environment (Department of Prime Minister and Cabinet 2003, Hong 2001, Housing New Zealand Corporation 2004a, 2004b).

Partnership in the Social Research and Policy Literature

As the Ministry of Social Policy (2000) review of partnership models cited earlier found, the literature from the empirical use of partnership fails to shed light on its utility. Partnership is often discussed in the literature as if its definition is unproblematic. There is little discussion on how partnership may differ from, or be the same as, other types of collaborative relationships and the reasons for taking a partnership approach are largely unquestioned in terms of its theoretical basis. Despite this, it is discussed widely and in a variety of areas of literature in the social policy domain.

Three distinct (although not mutually exclusive) ways of viewing partnership, in terms of social goals, emerge from the literature. The first is partnership as an extension of civic engagement – the way that people, groups and sectors participate in and influence the democratic process (Craig and Larner 2002, Drage 2002, Lynch 2002, Robinson 1999) . The second view is of a new form of social governance – how local organisations and central and local government engage, and manage responsibility and accountability issues, with each other (Baxter 2002, Craig and Larner 2002, Curtis 2003) . The third view is partnership as a means of delivering social goals – how to work across sectors and groups to find solutions to social issues (Casswell 2001, Cornwall and Jewkes 1995, Israel et al. 1998, Minkler and Wallerstein 2003).

Despite the different orientation of the views of partnership, several common theoretical themes are discussed and appear to be critical to the use of partnership. These common themes are:

• the connection between partnership and participation
• the impact of trust and power in relationships
• the importance of local knowledge to understanding the local context
• understanding the capacity of communities to change.

Partnership and Participation

Participation is most often described as levels of community involvement, from information sharing and consultation, to shared decision making and responsibility. Embedded in the values of democracy, participation has become a key policy tool and indicator (Craig and Larner 2002). It underpins many methods aimed at creating knowledge of, and influencing, the social and political environment.

In government processes, participation has become a dominant mechanism and goal, although not everyone views its current use positively. It has often been seen as tokenism and a matter of just counting the numbers of those consulted. Some see the rhetoric of participation as obscuring the “real” partial or limited involvement of communities in decision-making and governance issues (Grace 1991). This criticism of participation has also been extended to researchers where those being researched have sometimes been left feeling not just over-researched, but used by researchers to achieve their own personal or institutional goals (Smith 1999).

Partnership is described as sitting at a higher (or more formal) end of a continuum of participation where groups, organisations, institutions and sectors form relationships. Some have even likened it to a new form of social governance, where government has devolved responsibility (Craig and Larner 2002, Lynch 2002). Again, critics have argued that this devolution of responsibility is more about cost saving by government than it is about real sharing of power. Others, however, view this devolution positively and see it as enabling a sharing of decision making and responsibility (Drage 2002, Newelt and Crampton 2005).

Participation and partnership are undoubtedly intertwined, although participation can be – and often is – used in circumstances where there is no partnership relationship. They also both seem to suffer a similar fate, in that they are widely used to justify particular activities and approaches, but their use and purpose are often lost or not considered with serious rigour.

Trust and Power in Relationships

Power and trust are central to many discussions of partnership, and there is a vast literature on both within the public policy arena. The role of power in partnerships is discussed mainly in terms of the inherently unequal nature of government–community relationships. Trust, on the other hand, is often described as a facilitating feature of partnerships. One definition of trust is as a mechanism for “coping with the freedom of others”, its prime function being to reduce social complexity (Scambler 2001). Some discuss partnership as institutionalising trust around common goals, with norms of behaviour emerging through mutual acceptance (Israel et al. 1998). This definition of partnership implies a flexibility in the relationship and an acceptance that there may be a degree of uncertainty around where the relationship is going and how it will get there.

Power and trust in relationships are discussed in the literature as operating in subtle coexistence. In order for interactions to be open, the relations of power between players must be clear – that is, power must not be used deceptively. Contemporary philosophers Habermas and Rorty discuss the importance of communication that recognises the implicit purposes of communication that are dictated by power and influence. Rorty discusses the intentional aspects of language and communication (Krummenacher 2002), and Habermas describes what he terms the “ideal speech situation”, where people talk with each other without the interplay of power. He discusses communicative action, which, he explains, focuses on communication for understanding rather than strategic positioning. He theorises that the way people communicate and the language they use belie their real motivations. Much communication is for the purpose of achieving influence or causing particular actions, which Habermas regards as either conscious or unconscious deception (Scambler 2001). These ideas have been extended by some to clarify the way that the public sector (where goals must be in the public interest) should operate, and include or take account of the voices and knowledge of people in society (Krummenacher 2002). Government institutions that can recognise their influence on those they deal with are more likely to act and respond in appropriate ways.

The nature and characteristics of power are central to most policy analysis. However, the view of Rorty and Habermas power relations are fluid, able to be described and can be influenced through the actions of individuals and through organised efforts. Differences in capacity, infrastructure, knowledge, resources and access to political processes are some of the places where power imbalances arise between government and community. Perhaps being able to label a relationship as a partnership gives a more tangible place for issues of power to be reflected upon and addressed. If external relationships continue to be viewed as important to successfully delivering social goals, having ways to reflect on characteristics that impact on these connections, such as power, also becomes more important. For addressing health inequalities, some suggest it is impossible to conceive of solutions that ignore the role of power relations (Graham 2000).

Local Knowledge for Change

Another key theme that arises in the literature is the role of local knowledge in bringing about community change. There has been a shift to incorporating the local context in policy interventions in New Zealand that is illustrated by the activity around partnerships described earlier. The value of eliciting local knowledge to gain an understanding of the local context has been thought about in great detail by social researchers.

Participatory methods of inquiry such as “action research” and “community-based participatory research” are formed around ideas of inclusion and change within communities. When compared with more traditional forms of inquiry, they have a commitment to “action and helping to foster social change as an integral part of the research process” (Cornwall and Jewkes 1995, Minkler and Wallerstein 2003). Participatory methods offer insight into the processes of outsiders working with communities and using local knowledge to achieve better understanding and better outcomes. Partnership in this situation sees local knowledge as an invaluable way of gaining an understanding of the surrounding social context. Participatory researchers recognise that without local knowledge there would be limitations on their ability to implement their research and interpret findings (Israel et al. 1998).

Considering the context in which decisions are made and activities undertaken is crucial in situations where there are multiple levels of complex interactions. Those that observe the systemic nature of social problems caution against the prospect of finding effective solutions if the key elements of an evolving system are overlooked (Midgley 2000). The impact of historical events, power relationships and cultural mores defines people’s situations, and people have an either implicit or explicit understanding of, or resignation to, their situation. Capturing this kind of knowledge is often essential to understanding and acting appropriately (Thomas and Veno 1992). A partnership relationship may therefore be a more appropriate way to obtain this kind of input and knowledge.

Alongside the political influences that have led to partnership being used more widely there is the rise in popularity of other inclusive methods for achieving social change. These have originated mainly from work in the field of “development” that has explored ways to address the burden of poverty and disease within developing countries. Community development and other “bottom-up” approaches to achieving social change have become popular as a result, and are also used increasingly in New Zealand (Department of Internal Affairs et al. 2002).

Understanding Community Capacity

The development literature is also important for its discussions of the way individuals act and the way organisations act. The ability of communities to organise themselves has an impact on their capacity to participate in political processes, to take up opportunities and to develop a coherent picture of their own needs (Campbell and Jovchelovitch 2000, Casswell 2001, Greener 2002). Whereas social epidemiologists have focused on causes and outcomes, social and community psychologists have focussed on characteristics of implementation processes. They see community capacity, human agency and the process of change as being very important to the success of policies and interventions to reduce health inequalities (Cornwall and Jewkes 1995). Partnership-based implementation has particular relevance for social interventions if partnership leads and guides the approach and methods used. It implies starting from a point where there are already things known about achieving change in communities.

One definition of “intervention” is the “purposeful action by a human agent to create change” (Midgley 2000) . Indeed some critics of “third way” politics, which assume people want to change their circumstances given the right opportunity, cite a lack of understanding about human agency as a misjudgement in the way social policies are formulated and delivered. Critics say that policies that assume people are always in a position to change their own circumstances misunderstand both the context in which people live and the degree of control they have over themselves and their environment (Greener 2002, Hoggett 2001). A useful analytical distinction here is that between first-order agency (the ability or inability of people to change their own circumstances) and second-order agency (their ability or inability to influence the structures around them). Analyses and reflections on agency provide a way of exploring the interactions between individuals and organisations, and systems and structures. Those who critique social policy generally discuss this understanding of human agency as essential not only to achieving effective policies but also to having realistic expectations of outcomes (Greener 2002, Hoggett 2001, Judge and Mackenzie 2002, Thomas and Veno 1992, Watzlawick et al. 1974).

This view is not the sole domain of community psychologists. Even from within the current dominant language of health inequalities (at least from within the health sector), which emphasises cause, effect and measurement, those that review intervention “experiments” to reduce health inequalities suggest that there need to be more understanding and action around aspects of the implementation process. Examples of experimental community intervention research include smoking cessation programmes, early interventions to reduce obesity, income supplementation programmes, and interventions to improve housing conditions, to name a few (Sorensen et al. 1998).

Two recent comprehensive reviews of community interventions conclude that the results and findings, which are largely measured by quantitative outcomes, are equivocal (Atienza and King 2002, Sorensen et al. 1998) . However, rather than writing the interventions off as failures, in both cases the authors strongly support the value of the intervention and discussed the pressing need to reflect and understand more about theoretical issues and the process of implementation. They suggest that at least until more is known to inform community interventions, there needs to be a concentration on exploring context and process issues with an emphasis on the engagement with communities. These studies provide an example of the need to consider in depth the theory, processes and assumptions within interventions that attempt to orchestrate change in communities. The lesson for policy-driven interventions surely must be that a similar approach be taken.

Discussion

The current policy trend – to have the reduction of health inequalities as a desired outcome – indicates a serious attempt to deal with the complexity of social interactions. In theory, partnership seems to offer policy makers a way to respond to complexity in a flexible manner and is perhaps a way to cope with levels of uncertainty in implementing policy. If the reasons for using partnership approaches are taken seriously, policy makers should consider them in greater depth so that the potential for engaging in these types of relationships can be realised. This potential may be limited or appropriate only in certain circumstances, or a partnership approach may be widely applicable and provide significant long-term benefits. Depending on the outcome and depending on the community, more formal and prescribed contractual relationships may be adequate. But given complex social issues that arise in communities that are more distant from the mainstream, for example, perhaps the only way to successfully achieve positive outcomes is through operating in partnership. Many Māori, for example, have recognised the need to be realistic about such things as unaddressed power imbalances, and therefore see “relationships” as a means of solving the compromises of partnerships. However, the reasons and methods underpinning partnership should not be lost with such a compromise.

Some of the more obvious lessons that a review of the literature implies for interventions include: partnerships should enable power issues to be reflected upon and addressed; they should enable information and insight from within communities to be used to help inform decisions and directions; and the capacity of communities to embrace or adjust to change should be considered. Less obvious, perhaps, is how outcomes are viewed. Having a more flexible notion of outcomes – and more realistic expectations – may be an appropriate way to view complex, evolving and longer-term social problems. Efforts to measure the benefits of interventions have been equivocal, but we need to be critical of both what is being measured and the time scale used for assessing outcomes. For example, established relationships may mean trust has been built up over time, which provides opportunities for partners in that relationship to respond flexibly and more appropriately to issues as they arise. These aspects of the policy implementation process will not be captured in some circumstances if short-term, measurable or specific outcomes are the sole focus of evaluations.

This paper has largely discussed partnership in the context of the community setting. This analytic focus on the characteristics of the community in a partnership reflects the emphasis found in the literature, which, in itself, seems to highlight the lack of attention paid to government partners. It is less common to find the more powerful partner in a relationship subject to similar analyses, although in New Zealand there have been significant instances of critically addressing the way government operates in relationships (Community and Voluntary Sector Working Party 2001, Community–Government Relationship Steering Group 2002). Each of the themes described in this paper could perhaps be equally applied to government organisations or institutional settings to gain further insight into the context in which they operate and, perhaps, the barriers and enabling factors that determine their ability to form responsive relationships. In order to understand more about the utility of partnerships, more effort and analyses should be carried out on the culture and context of the dominant institutions, their ability to respond to change and their ability to be self-reflective so that power issues in their external relationships can be addressed. To do justice to the ideas of working in partnership to address complex social problems, such as reducing health inequalities, the theory and practice need to be considered far more carefully.

References

Ajwani, S., T. Blakely, B. Robson, M. Tobias and M. Bonne (2003) Decades of Disparity: Ethnic Mortality Trends in New Zealand 1980–1999, Ministry of Health and University of Otago, Wellington.

Atienza, A. and A. King (2002) "Community-based health intervention trials: An overview of methodological issues" Epidemiologic Reviews, 24:72–79.

Baker, M., J. Milosevic, T. Blakely and P. Howden-Chapman (2004) "Housing, crowding and health" in P. Howden-Chapman and P. Carroll (eds.) Housing and Health: Research, Policy and Innovation, Steele Roberts, Wellington.

Baxter, K. (2002) "Community/government relationships: Issues in establishing formal linkages between central government and the community sector" Strengthening Communities Through Local Partnerships Symposium, University of Auckland, Auckland.

Berkman, L. (2004) "Introduction: Seeing the forest and the trees: From observation to experiments in social epidemiology" Epidemiologic Reviews, 26:2–6.

Berkman, L. and I. Kawachi (eds.) (2000) Social Epidemiology, Oxford University Press, Inc, New York.

Boston, J., P. Dalziel and S. St John (eds.) (1999) Redesigning the Welfare State in New Zealand, Oxford University Press, Auckland.

Campbell, C. and S. Jovchelovitch (2000) "Health, community and development: Towards a social psychology of participation" Journal of Community and Applied Social Psychology, 10:255–270.

Casswell, S. (2001) "Community capacity building and social policy: What can be achieved?" Social Policy Journal of New Zealand, 17:22–34.

Coleman, J.S. (1990) Foundations of Social Theory, Harvard University Press, Cambridge, Massachusetts.

Community and Voluntary Sector Working Party (2001) Communities and Government: Potential for Partnership, Whakatopu Whakaaro, Ministry of Social Policy, Wellington.

Community-Government Relationship Steering Group (2002) He Waka Kotuia: Joining Together on a Shared Journey, Ministry of Social Development, Wellington.

Cornwall, A. and R. Jewkes (1995) "What is participatory research" Social Science and Medicine, 4:1667–1676.

Craig, D. and W. Larner (2002) "Local partnerships and social governance in Aotearoa New Zealand" Strengthening Communities through Local Partnerships Symposium, University of Auckland, Auckland.

Curtis, B. (2003) Third Way Partnerships, Neo-Liberalism and Social Capital in New Zealand, Research Paper No. 4, University of Auckland, Auckland.

Department of Internal Affairs, Ministry of Social Development, Child Youth and Family, and Community Employment Group (2002) A Framework for Developing Sustainable Communities, discussion paper, Department of Internal Affairs, Wellington.

Department of Prime Minister and Cabinet (2001) Statement of Government Intentions for an Improved Community–Government Relationship, Department of Prime Minister and Cabinet, Wellington.

Department of Prime Minister and Cabinet (2003) Sustainable Development for New Zealand: Programme of Action, Department of Prime Minister and Cabinet, Wellington.

Dew, K. and A. Kirkman (2002) Sociology of Health in New Zealand, Oxford University Press, Melbourne.

Drage, J. (2002) Empowering Communities?: Representation and Participation in New Zealand's Local Government, Victoria University Press, Wellington.

Giddens, A. (1998) The Third Way: The Renewal of Social Democracy, Polity Press, Cambridge.

Grace, V. (1991) "The marketing of empowerment and the construction of the health consumer: A critique of health promotion" International Journal of Health Services, 21:329–343.

Graham, H. (ed.) (2000) Understanding Inequalities, Open University Press, Buckingham.

Greener, I. (2002) "Agency, social theory and social policy" Critical Social Policy, 22:688–705.

Hoggett, P. (2001) "Agency, rationality and social policy" Journal of Social Policy, 30:37–56.

Hong, B. (2001) Improving The Knowledge Base For Social Policy: Strategic Knowledge Needs, Ministry of Social Development, Wellington.

Housing New Zealand Corporation (2004a) Initiatives: The Rural Housing Programme in Northland, East Coast and Eastern Bay of Plenty

Housing New Zealand Corporation (2004b) Initiatives: Community Renewal

Howden-Chapman, P. (1993) "Doing the splits: Contracting issues in the New Zealand health service" Health Policy, 24:273–286.

Howden-Chapman, P., J. Crane, M. Baker, C. Cunningham and A. Matheson (2004) "Reducing health inequality through improving housing: He Kainga Oranga / Housing and Health Research Programme" in P. Howden-Chapman and P. Carroll (eds.) Housing and Health: Research, Policy and Innovation, Steele Roberts, Wellington.

Howden-Chapman, P. and M. Tobias (2000) Social Inequalities in Health: New Zealand 1999, Ministry of Health, Wellington.

Israel, B., A. Schultz, E. Parker and A. Becker (1998) "Review of community-based research: Assessing partnership approaches to improve public health" Annual Reviews Public Health, 19:173–202.

Jackson, M. (1998) "Research and the colonisation of Mäori knowledge" Proceedings of Te Oru Rangahau Mäori Research and Development Conference, Massey University, Palmerston North.

Judge, K. and M. Mackenzie (2002) "Theory-based evaluation: New approaches to evaluating complex community-based initiatives" in J. Mackenbach and M. Bakker (eds.) Reducing Inequalities in Health: A European Perspective, Routledge, London.

Krummenacher, S. (2002) The Debates of Jurgen Habermas and Richard Rorty: Implications for the Conceptualization of Public Administration, Public Administration Theory Network, www.pat-net.org/Krummen.html.

Lynch, J. (2002) "Working in partnership" in J. Drage (ed.) Empowering Communities?: Representation and Participation in New Zealand's Local Government, Victoria University Press, Wellington.

Mackenbach, J. and M. Bakker (2002) Reducing Inequalities in Health: A European Perspective, Routledge, London.

Midgley, G. (2000) Systemic Intervention: Philosophy, Methodology, and Practice: Contemporary Systems Thinking, Kluwer Academic / Plenum Publishers, London.

Ministry of Health (2001) The Primary Health Care Strategy, Ministry of Health, Wellington.

Ministry of Social Policy (2000) Models of Community–Government Partnerships and their Effectiveness in Achieving Welfare Goals: A Review of the Literature, Ministry of Social Policy, Wellington.

Minkler, M. and N. Wallerstein (2003) Community-Based Participatory Research for Health, Jossey-Bass, San Francisco.

Newelt, P. and P. Crampton (2005) "Community participation in primary health care in Aotearoa New Zealand" in K. Dew and P. Davis (eds.) Health and Society in Aotearoa New Zealand, 2nd ed., Oxford University Press, Melbourne.

NZAID (2003) Strategic Policy Framework for Relations between NZAID and New Zealand NGOs, NZAID, Wellington.

Oxford University Press (2001) The New Oxford Dictionary of English, Oxford University Press, New York.

Putnam, R.D. (1995) "Bowling alone: America's declining social capital" Journal of Democracy, January:65–77.

Robinson, D. (1999) Partnership: From Practice to Theory, Policy Paper No. 2, Institute of Policy Studies, Victoria University of Wellington, Wellington.

Royal Commission on Social Policy (1988) Future Directions, Vol. II, Royal Commission on Social Policy, Wellington.

Scambler, G. (2001) Habermas, Critical Theory and Health, Routledge, Taylor and Francis Group, London and New York.

Smith, L.T. (1999) Decolonizing Methodologies, University of Otago Press, Dunedin.

Sorensen, G., K. Emmons, M.K. Hunt and D. Johnston (1998) "Implications of the results of community intervention trials" Annual Reviews Public Health, 19:379–416.

Thomas, D. and A. Veno (1992) Psychology and Social Change, Dunmore Press, Palmerston North.

Treasury (2003) Guidelines for Contracting with Non-Governmental Organisations for Services Sought by the Crown, Treasury, Wellington.

Watzlawick, P., J. Weakland and R. Fisch (1974) Change: Principles of Problem Formation and Problem Resolution, W.W. Norton & Company Inc, New York.

Footnotes

¹ Acknowledgements
We would like to thank the following people for discussions around some of the ideas and for advice on coherence and structure: Barbara Israel, Michigan Centre for Environment and Children’s Health; Bridget Robson, Eru Pōmare Māori Health Research Centre, Wellington School of Medicine and Health Sciences; Chris Cunningham, Te Pūmanawa Hauora, Massey University; and Ross Bell.
Correspondence
Correspondence to Anna Matheson, Programme Manager, He Kainga Oranga / Housing and Health Research Programme at the Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago, Phone +64 4 385 5999, Email: amatheson@wnmeds.ac.nz

² Philippa Howden-Chapman is Director of He Kainga Oranga / Housing and the Health Research Programme.

³ Now the Ministry of Social Development.

⁴ Provider capture is seen when there are perverse incentives for the delivery of public sector services due to the unequal or asymmetrical availability of information.

⁵ www.hnzc.co.nz  www.msd.govt.nz

⁶ http://www.moh.govt.nz

⁷ Now called New Zealand Trade and Enterprise.

⁸ http://www.waitakere.govt.nz/ourpar/strengthcomm.asp