Developing the model for cross-sectoral cooperation for promoting health and wellbeing

In the rapidly progressing world where different sectors become more interconnected, cross-sectoral cooperation in health promotion lacks a specific set of instruments, navigating partners through the cooperation process in project implementation. Cross-sectoral cooperation is an everyday practice in business and has become an integral part of promoting health and wellbeing comprehensively and sustainably. In this paper, we propose a developed Model for cross-sectoral cooperation, which has been designed within the Interreg Baltic Sea Region project “Urban Labs for Better Health for All in the Baltic Sea Region” (Healthy Boost), aiming to boost cross-sectoral cooperation for health and wellbeing in cities and municipalities. The Model is developed based on literature research and self-assessment of cross-sectoral cooperation for health promotion in Healthy Boost partner cities and municipalities in Latvia, Poland, Russia, Finland, Estonia, Lithuania, and Sweden. Composed of five major domains (risk identification, leadership, coordination, communication, and motivation) and four stages of cooperation (mapping, planning, implementation, and assessment), it provides a checklist of helpful questions for identifying solutions effectively and systematically. The Model can be used both as a navigational tool and as an “emergency” tool to manage cross-sectoral cooperation challenges successfully.


Introduction
One of the key motives for cooperation is the belief that working together is more effective than working individually. Therefore, partnerships should be formed, bringing together different actors in collaborative actions and efforts to exert change [1]. Partnerships provide a managerial response to the general idea of societal progress, where different parts of society can work and cooperate towards a common goal [2]. On a broader scale, cross-sectoral efforts can improve the quality of support to target groups and sectors, increase effectiveness and develop a multidimensional orientation [1].
For businesses and corporations, cross-sectoral cooperation is a well-known and practiced approach to achieve common goals. However, more guidance is needed to tackle different challenges and interests of partners from various backgrounds and experiences in health promotion. Promoting health and well-being in today's modern society is essential for ensuring a better living for our individuals and communities. It is acknowledged that medical professionals and health practitioners cannot address the challenges on their own. Instead, a more comprehensive approach in terms of involved parties is required. Local governments, schools, food suppliers, businesses, and civil society organizations all play a role.
The aim of this research is to develop and propose a universal tool -a Model for crosssectoral cooperation that can be applied when partnerships between different actors occur in promotion of health and well-being. The main tasks of this article are: to conduct a comprehensive literature review on cross-sectoral cooperation; to propose the main components of the Model in the form of stages and domains of cooperation, based on the literature review; and lastly -to propose the Model for cross-sectoral cooperation, outlining the functionality of domains and stages that the Model contains and their applicability in the enhancement of the cooperation process.
Cooperation is an important tool for encouraging collective action, exchanging knowledge, and empowering various public groups to act and live a healthier lifestyle [2]. However, partnerships may be difficult to set up and maintain because they require strong motivation and sufficient resources, and the collaboration results usually are not immediate [1]. Nearly half of all partnerships are short-term and fail within the first year. Nevertheless, the value and importance of establishing partnerships are acknowledged [3].
At the end of the last century, cross-sectoral cooperation received a lot of attention in public health policy. Since the late 70's, cross-sector cooperation as a concept has been used to describe partnership and coordination that the public health sector can establish with representatives of other specialties. The enduring use of this concept in the health sector shows the effectiveness of coordinated action in health promotion [4]. Collaboration is no longer limited to a single sector but increasingly involving cross-sector agreements, which may result in complementarity and synergy of otherwise scattered resources [5]. The spread of non-communicable diseases (NCDs) and other modern health challenges, caused by the interaction of the lifestyle choices and the environment, have contributed to the recognition of the need to explore cross-sector cooperation, involving the private sector, non-governmental organizations (NGOs), industry leaders, public and health sector to improve health of the population.
Although the definitions of cross-sectoral cooperation vary, common elements can be identified. Cross-sectoral cooperation means partnerships of different partners sharing their resources and responsibilities to achieve a common goal. The partnerships promote the additional value, increase resources, establish new networks between different partners, enhance mutual understanding, and prevent duplicating efforts to meet local needs. Cross-sector partnerships facilitate access to various skills, promote innovation, increase social participation, and reduce conflicts between local entities. This article proposes a developed Model for cross-sectoral cooperation, which can be considered a universal and comprehensive navigation tool for cross-sectoral cooperation in projects on health and well-being.

Different approaches to cross-sectoral cooperation
In literature, the mutual efforts exerted in working towards a common goal are defined and described from various perspectives, resulting in multiple definitions of cooperation, partnerships, cross-sectoral cooperation, and collaboration. Corbin and Mittelmark (2008) define cooperation as synergy between different partners to improve their ability to be creative, holistic, realistic, act and be accountable, when implementing projects or working towards a common goal [5]. Cooperation is defined as a collaborative, integrated, and long-term endeavour in which various entities strive for appropriate operational efficiency by combining forces and resources and achieving a synergistic effect [5]. Moreover, cooperation within a partnership is collaborative and it is effective only when partners share a strategic vision, pursue compatible objectives, and are equal members in the cooperation, according to Brandstetter et.al. (2006) [1]. Whereas a partnership is described as co-participation [5] and an agreement to do something together, benefiting the involved and bringing results that could not be achieved by a single partner [1]. Glasbergen defines partnership as shared decisionmaking around agenda setting, goals and strategies, describing a range of interactions among public health entities, NGO's and the private sector [2]. In turn, Wyrwa describes collaboration as the characteristic of each organized action or activity, which is determined by different links between individuals and social groups working together towards a common goal. As the Overseas Development Institute (ODI) and the International Business Leaders Forum (IBLF) define, cross-sector partnership is a voluntary, informed, and strategic alliance of partners representing various public, commercial, and non-governmental sectors [5]. Specifically, cross-sector partnership is defined as a voluntary collaboration of entities in the process of identifying and defining problems that concern public tasks, and jointly working towards their solution, while maintaining the principle of equality in sharing resources, accountability, risks, and benefits [5]. When discussing cross-sectoral cooperation in the realm of health policymaking, authors use cross-sectoral cooperation to describe the joining of different sectors to work together to produce a broader view for institutions to make a better contribution to cross-sectoral cooperation. This in turn, can reduce the number of conflicting policies and tackle broader issues by promoting policies that are better interconnected and mutually supportive [4]. We defined cross-sectoral cooperation as a collaborative effort in which partners from different sectors (public, private, and non-profit) pool their resources to provide joint solutions for the common wellness, and to address health challenges.
Cooperation between representatives of different sectors usually deals with complex questions and issues, therefore includes a number of intricate decision-making phases. The Partnership Life cycle contains two phases and four steps: (1) formation phase (initiation/exploration and building) and (2) execution phase (implementation and institutionalization and/or extension) [6]. Cross-sectoral cooperation, collaboration, partnerships -the different definitions given to collective efforts towards a common goal -is not the only flexible element in the structure on the topic of cooperation. When conducting the literature review, one will find many different interpretations of what a partnership or cooperation is, or how to describe the best collective efforts and different elements proposed by authors as to what matters most in cooperation and its basic structure.
Developing the Model, we strived to base it on the most flexible and universal principles that can be applied in a variety of health promotion projects, i.e., from promoting health and well-being in single interventions to large-scale sustainable development projects. This section provides a summary of the main stages of cross-sectoral cooperation identified in the literature review, which were used to construct the Model for cross-sectoral cooperation.
The proposed number of stages for cross-sectoral cooperation varied. The number of stages is determined by the level of detail with which we view collaboration and, most likely, by the project at hand. For, example, not all partnerships will result in institutionalization or setting up a new institution as Wadell and Brown (1997) suggest [7]. It is also very possible that we do not need a developed exit strategy from the cooperation [10]. It was agreed that the early stages of cooperation, on which the partnership builds upon, are crucial. This is the time in the cooperation the problem or goal is being acknowledged and partners are brought together [6]. However, social research has thus far focused on the implementation phases of cooperation, although the scholars have recently acknowledged that many failures in The Intersector Project [13] Diagnosis -can intersectoral collaboration help solve our problem? Design: how do we lay the foundation to operationalize our common intersectoral vision? Implementation: hoe does our intersectoral collaboration achieve its goals? Assessment: what lesson did we learn from our intersectoral collaboration?
cross-sectoral cooperation begin at the very beginning of cooperation formation [6]. Whether it is to identify the conditions for cooperation, define goals, acknowledge potential partners, get the senior level on board for the project, or recognize that cooperation is needed to solve the problem, an initiation or pre-cooperation stage is in place in all cooperation models. Several key aspects or tasks in the beginning or initiation of cooperation have to be taken into consideration: Defining goals. Partners should have a shared vision, strategy, and commitment to the project for it to be successful [1]. In academic research, the importance of commitment and goal symmetry originates in alliance formation studies, where it was found that although the parties agree to pool their resources together, they frequently disagree on the aims of cooperation [6], therefore clear articulation of goals in cooperation is detrimental for achieving success and accountability [14]. The agreement on shared goals and ideals' outcomes should clarify the mission and priorities of the cooperation and define a common purpose, link stakeholders together, and create a mutual understanding of the benefits of success [13].
Choosing partners. Careful partner selection is required for the partnership approach to be fruitful, to enable effective relationships, and to ensure that partnership activities are sustainable. The size and structure of the partnership should reflect its aims and the issues it is addressing that can range from associations of local towns and municipalities to governmental institutions and school boards [1]. In the initial stage, the identification and engagement of individuals and organizations with a stake in the issue the collaboration wishes to address should be determined. The suitability and interest of partners to join the cooperation needs to be assessed from the very beginning. Careful consideration and selection of partners is crucial to ensure that the collaboration is built upon connected networks and efforts of any of important partners [13]. Choosing appropriate partners for cross-sectoral cooperation can be a challenge. When considering potential partners, the first-choice decision to make is whether to involve partners based on pre-existing cooperation and experience, or realize of a common issue between different actors, that can be best solved by cooperating. The image and policies, values, and beliefs of partners that are involved in the cooperation should be considered. It is necessary to consider the extent to which the potential partners are in line with the main goal to be achieved jointly [6] by making sure that partners share the same interests or at least the interests do not conflict [14]. However, it is found that organizations most likely choose partners that they have previously cooperated with rather than unknown entities. Partners' previous experiences also matters, whether they have had previous crosssectoral cooperation projects, or any cooperation projects at all [6]. One of the things that should be considered is getting all of the relevant actors to join the partnership, whether they may be part of the problem or a part of the solution. If this is not taken into account, the options for achieving the goal of cooperation may be limited [1]. The next cluster of stages aims to get the partners to start actually working together towards the goal by: Choosing the leader. Partners within the partnership should understand their roles, what they bring to the alliance, what to expect from others, and what is to be achieved together or what is expected of them individually. Each individual partner usually has more than one role and function, and all roles and functions are important to the overall success of the partnership. Partnerships are required to reflect on their overall function, their obligations and limits, and their responsibilities and restrictions. If partnerships are uncertain about their key function, reaching all targets and plans of cooperation become challenging [1]. The creation of a formal or/and informal organizational system for decision-making and project management gives clear governance structures, provides direction, while maintaining equity and inclusivity to resolve actual or perceived power imbalances that can arise during cooperation [13]. The selection of an individual or organization that is responsible for coordinating tasks that allow the cooperation to progress, be it an individual person, a body of managers or an organization as a single point of accountability, can ensure structure, and instil confidence in the process of cooperation [13]. It also should be taken into consideration that in each partnership, there will be "followers" as well as informal "leaders" who somehow gain the "upper hand" in the partnership. Partnerships often benefit from the leadership role taken by organizations in power, as leaders often turn out to be an important factor in pushing the cooperation and related activities forward. However, stronger partners can also hinder others, consciously or not, from making their full input; therefore, a partnership should reflect the strengths of all partners and minimize the weaknesses [1].
Communicating with partners. Demands can be met only if partners are clear about their raison d'être and communicate their responsibilities and competences as well as the boundaries of their abilities and capacities [1]. Openly sharing information among partners, including disclosing sensitive facts, gives partners a more comprehensive understanding of the issues and builds trust [13]. Allowing the cooperation to address partners' differing priorities creates channel to hear and respond to their perspectives and concerns, and the cooperation acknowledges the conflicting opinions that can arise from the distinct values and goals of each partner, establishing a forum for building consensus, and nurturing and understanding across organizations and sectors [13]. First, all partners should develop a communication strategy and prepare regular action plans deriving from that strategy. Communication has both an internal and external role. Regarding the former, it is crucial to the functioning of a partnership to ensure that a clear information flow among partners. Good communication will facilitate meetings, decisions, and interactions between partners. The external role of communication is to ensure that the work of the partnership is visible, in order to organize support and funding. There is a need to agree on the rules and principles for external communication among all partners [1]. "Informal" ways of networking should be complemented by structured forms of communication (i.e., websites, newsletters [1]. In communication -creating an environment in which partners can communicate [13], and transparency of communication, allows building trust and mutual understanding [5]. In internal communication, transparency comes from sharing results and insights into the cooperation process, enabling partners to communicate the value and legitimacy of cross-sectoral cooperation [13]. However, the balance should be maintained regarding frequency, relevance, and quality in communication [3].
Although considered one of the most important pillars for partnership formation and endurance, defining goals, choosing leaders, and communicating with partners and other audiences are not the only contributory factors to successful cooperation. Resource planning, monitoring, and assessment are also a couple of the many things to consider.
Estimation of resources, both financial and non-financial, available at the disposal of the project [13] is also a key element of success to meet the goals of cooperation.
Monitoring and assessment are also crucial for a successful partnership to assess both the effectiveness of cooperation and the efficiency of achieving the goal of the cooperation [14]. While planning helps identify the objectives to be reached and the work to be done from the outset, a good assessment and monitoring process helps to assess, throughout the project, whether operations are relevant and results satisfactory and to gauge the partnership's true impact [1]. The assessment process should start at the very beginning of the partnership. It is necessary to identify indicators to evaluate the progress and results of the collaboration. The consensus among partners on what will define success for the collaboration in the short, mid and long term creates accountability and helps the collaboration track towards the goal [13].

Content of the Model for cross-sectoral cooperation
The Model for cross-sectoral cooperation has been developed based on literature review and the results of the self-assessment of cross-sectoral cooperation for health promotion by professionals and experts in Healthy Boost collaborate cities. The Model has drawn from previously developed models of cross-sectoral cooperation such as the Bergen model of collaborative functioning [3] and others discussed in the table above. The Model provides a general framework for cross-sectoral cooperation, guiding partners through best practices of cooperation by using a systematic approach.
The various models available are by definition not intended to solve every day practical problems. Instead, the models usually provide some general framework of the processes that can be used to enhance confidence and better practice. The developed Model for crosssectoral cooperation focuses on the process of cooperation in general and not the project implementation. It can be applied in various kinds or cross-sectoral cooperation and in different circumstances. Different types of partners (i.e., governmental organizations, institutions, NGOs, SMEs) and partners on varying levels of involvement (i.e., leaders, project managers, assistants, employees) can use the Model. The Model is two-dimensional and can be used both either selecting a specific domain or stage of cooperation as a starting point. The Model provides main guiding questions for boosting the cross-sectoral cooperation in a particular domain in a particular stage of cooperation. The Model does not aim to grade the cooperation, but to self-check the cooperation process.
In general, five domains and four stages of cross-sectoral cooperation are presented in the Healthy Boost Model for cross-sectoral cooperation. The 5 domains are explained in more detail below.
The four stages of cross-sectoral cooperation are in line with project implementation stages. However, the stages within the Model are used and defined concerning the process of cooperation, not the project implementation as such. Therefore, in terms of this Model, the mapping stage of the cooperation is considered the preparatory stage where partners reflect upon previous experiences and current situation regarding cooperation and partner availability. In the planning stage, partners can set strategic goals and activities, which should be implemented during the cooperation. Lastly, assessment is the evaluation stage where partners are ready to evaluate their collaboration.
Risk identification is the process of determining, assessing, and managing risks that could potentially prevent effective cooperation and the achievement of cross-sectoral cooperation goals. In the mapping stage of cooperation, potential partners must consider why and when they need to cooperate by considering the benchmark of successful cooperation for each organization.
Partners need to identify the key characteristics of potential partners that will ensure their credibility. Partners' reputation is a factor that has to be considered when starting crosssectoral partnerships. More detailed analysis and acquaintance of partners is necessary to avoid conflicts of interest regarding the goal of building cross-sectoral cooperation [6]. In the planning stage, partners need to consider how to best formulate realistic objectives for all parties involved. They have to consider also how to prevent possible inequality of commitment among partners and be aware of partners' honesty when providing the needed basic information for cooperation. Implementation is the acting phase of cooperation. All partners can see the result of planning and preparation taken in the previous stages at this stage. Specifics tasks and responsibilities by all partners according to the previously agreed plan have to be accomplished. Experiences and perceptions of whether responsibilities have been shared fairly between partners can vary. When assessing the cooperation, the partners have to realize the importance of evaluation and the possible factors that can hinder it. It is important to agree among all partners on the data and methods used for the assessment of cooperation.
In network management and conflict resolution literature, it has been identified [6] that leadership effectiveness is closely correlated with the positive outcomes of cooperation [3]. Leadership is the ability of individual or group to motivate and guide others to act towards achieving common goal. Managing is about organizing and coordinating, but leading is about enabling and co-creating. Five leadership attributes are identified as critical: professional recognition; values; developing relationships with the subordinates; skills in conflict resolution; strategic thinking [3]. Therefore, these are some of the qualities to consider for the partners in the mapping stage of cooperation, along with putting down their possible responsibilities. In the planning stage, partners should consider the key leadership factors and acknowledge the support that other partners could provide to the leader. When implementing cross-sectoral cooperation, it is important to consider how to ensure that goals and objectives are being met and the teamwork is successful. Assessment of leadership can be an ambiguous task. However, still, partners should consider how to assess the leadership experience for future reference -what are the criteria, and what components of leading can or should be evaluated.
Communication is a two-way process of reaching mutual understanding, in which participants not only exchange information, news, ideas, and feelings but also create and share meaning. It is a key function of management -communication among different partners, levels, departments, and employees. The mapping stage for communication should consider planning communication tools with partners and mapping possible factors like established partner internal communication systems into account. When planning communication, the best communication practices and both the resources and networks available to partners regarding internal and external communication should be considered. In the implementation phase of cross-sectoral cooperation, partners should consider the most effective communication elements in the particular partnership, considering how communication among partners is being managed and the key topics. In the assessment stage, partners should divide the partnership's internal and external communication dimension and assess each one separately by previously constructed criteria like transparency, frequency, ethics, etc.
The definition of cross-sectoral cooperation indicates a degree of interdependence, i.e., the willingness to pool resources to reach a common goal or face a common threat. Resources that each party can contribute to the partnership can be skills, access to specific areas of interest, legitimacy, reputation [6], expertise, emotional inputs of establishing relationships, professional inputs such as experience, financial contributions, etc. [3]. Coordination is synchronization and integration of activities, responsibilities, and command and control structures to ensure that the partners cooperate in the most effective way to reach the specified objectives. In the mapping stage, reflecting on the past experience in the distribution of resources and tasks among partners in cross-sectoral cooperation can help gain perspective and insight into the new partnership, considering who are the potential partners in the particular project. Planning coordination among partners is one of the crucial pillars of successful cooperation and project implementation. Several key things have to be considered: what resources are available; how to accommodate each partner's management styles; and how and on what principles the roles and responsibilities will be assigned. In the implementation phase, it is needed to start thinking about measuring cooperation and monitoring the progress. The assessment phase should focus on outlining and assessing the key area of cross-sectoral cooperation, like leadership, ethics, contribution, and performance of partners, etc.
Partners' motivation is one of the domains that should be considered and taken care of in partnerships [6]. Motivation is the force that initiates, guides, and maintains partners' goaloriented behavior in cross-sectoral cooperation. Shared goals and values among partners are crucial elements for motivation to cooperate, although goal alignment does not guarantee complete success. Each partner may have their specific reasons for cooperation; however, the partners have to make sure that the individual goals of each partner are not in contradiction to the primary goal of the cooperation [6]. Feeling connected and effective, can enhance partner motivation, but during cooperation, partners may experience different setbacks and negative feelings, such as contributing too many resources, that cooperating is too time-consuming in itself, partners may have to compromise too much, contributing to losing control and accountability [3]. Partners should focus on determining factors that could motivate them to cooperate during the mapping and planning stages. Rewarding partners' performance should be considered as a separate activity. It is important to monitor what maintains partners' motivation in this particular cross-sector cooperation project in the implementation phase. Motivation assessment should be considered a task occurring throughout the project by identifying the areas of cross-sectoral cooperation where it is crucial to assess the partners' motivation. The indicators used for motivation assessment may include resource sharing, commitment, leadership and participation levels, etc.
The Model for cross-sectoral cooperation has been developed to be a universal tool, that can guide, enhance, and contribute to better goal achievement experience for partners. Taking into mind the various situations, goals and challenges, which partners can potentially face in the process of cooperation, the goal of this model is to educate, promote awareness, and provide guidance for everyday or extraordinary situations or setbacks that occur with a persistent regularity in cross-sectoral cooperation. Its flexibility in use, topics that are considered here provide a combination of the most necessary and important guiding points for the management and participation in the cooperation process.

Conclusions
The role of health and well-being in the experience and actions of individuals, organizations, businesses, and policymakers has continued to grow in recent years, with societies becoming more concerned and more involved and investing in healthier lifestyles and choices. Health promotion requires the participation of different actors in the health and other areas, which can pose challenges for partners from different backgrounds and cultures and different goals and priorities.
The Model for cross-sectoral cooperation provides the checkpoints and reference points for different stages of cooperation and different challenges in communication, coordination, leadership, risk identification, and motivation aiming to contribute to a more effective and systemic cooperation for better health promotion.