Challenges and Solutions for Collaboration Among a Nonprofit Organization,Primary Care,Private Healthcare,and the Community Sector: An Instrumental Case Study

Introduction

People with “complex needs” often have unaddressed biopsychosocial concerns. ¹ They may face numerous social issues, such as an inability to secure a safe home; pay for food, medicine, or transportation; avoid harmful relationships; and maintain connections with friends, family, and other members of their communities.^2,3 To respond effectively to these individuals’ needs, service providers must consider the full range of factors influencing their health and well-being. ⁴ However, significant barriers to information sharing and care coordination between providers exist, as health and mental health services are often provided in isolation.^1,5,6

Primary health care provides a solution that responds to the biopsychosocial needs of a local population by improving access to comprehensive, continuous, and high-quality health and social care.^7,8 To achieve this, primary healthcare establishes interventions within and across sectors through intersectoral collaboration.^7,8 Allen et al, ⁹ drawing on Bialek et al ¹⁰ and Bryson et al, ¹¹ defined intersectoral collaboration as the “coordinated efforts of governmental and nongovernmental agencies from multiple aspects of society to address public problems.” Such collaborations—bringing together actors from various sectors of society—can more effectively influence key determinants of health, including material disadvantage and psychosocial stressors. ¹² Compared to isolated efforts by the health sector, intersectoral approaches are generally more effective, efficient, and sustainable in improving population health outcomes. ¹³ When collaboration is successful, the pooling of complementary resources, perspectives, and expertise leads to more innovative and impactful solutions. ¹⁴ Among the key partners involved in these collaborations are nonprofit organizations (NPOs), which in Canada, are defined as “associations, clubs, or societies that are not charities and are organized and operated exclusively for social welfare, civic improvement, pleasure, recreation, or any other purpose except profit.” ¹⁵

Intersectoral collaboration can be challenging because it requires diverse knowledge and skills from various actors and organizations. ¹⁶ Alderwick et al, ¹⁷ in a systematic review of reviews, identified five dimensions that influence intersectoral collaboration for health improvement: (1) motivation and purpose, (2) relationships and cultures, (3) resources and capabilities, (4) governance and leadership, and (5) external factors. While numerous studies have highlighted individual factors that support partnerships, Alderwick et al ¹⁷ noted a lack of evidence on how these elements interact and influence one another within collaborative processes.

Our understanding of intersectoral collaboration to address the health problems of people with complex needs is primarily derived from the experience in urban communities. In contrast, rural collaboration remains relatively understudied. ¹⁸ More research is needed to better understand the unique challenges faced by rural areas when implementing intersectoral collaborations. ¹⁸ For example, rural settings often contend with limited resources and significant geographic distances between partner organizations. ¹⁶ Despite the growing role of the nonprofit sector in delivering health and social services, particularly in response to rising demand and pressure for greater efficiency, ¹⁹ collaborative practices within this sector remain largely under-researched. ²⁰

The study had two aims: (1) to describe intersectoral collaborations for health improvement between an NPO and its social and primary health care partners in a rural setting and (2) to identify the factors that facilitate or challenge these collaborations.

Methods

Results

The case story below (Table 1) provides a comprehensive account of the case, its context, and the key factors influencing intersectoral collaboration.

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Table 1.

Case Story.

Case story

In the spring of 2021, a teacher-researcher, a social worker, and FMG physicians from different organizations responded to a government call to improve access to local services for a vulnerable population. Their initiative sought to foster collaboration between physicians, the health and social services network, and community organizations. Funding was secured that summer. However, since the FMG could not receive the funds directly, the initiators turned to a family community organization to manage the funds. The organization’s board declined, creating early tensions. In response, the project team founded a new non-profit organization (NPO), which operated from within the FMG’s premises. Initially, the teacher-researcher and social worker took on the demanding task of managing the NPO. By winter 2022, both had stepped back—one due to workload, the other to refocus on clinical responsibilities. A citizen-led board was formed, and 1 member assumed the role of director. Shortly after, the social worker resigned, citing disagreements over the project’s direction. As the NPO gained autonomy under new leadership, communication with the FMG deteriorated. Mistrust grew, and visions diverged. The FMG expressed concern and frustration over decisions made without consultation. These tensions affected staff morale, with some considering resignation. The rural context added complexity, as overlapping roles—such as physician–patient relationships among collaborators—blurred professional boundaries. The CISSS criticized the NPO’s vague service offering, fearing duplication and client confusion. Meanwhile, the family community organization, still dissatisfied with earlier interactions, remained hesitant to collaborate. Despite these challenges, some partnerships flourished. A private physiotherapy center, involved from the outset, finalized a collaboration framework with smooth communication. A partnership with a doula was also established with ease. In winter 2023, the NPO director resigned, citing workload and strained relations with FMG physicians. Their lack of clinical experience had hindered the development of a clear service offering and collaboration framework. A new director, unfamiliar with the region and lacking overlapping roles, took over. Tensions persisted, and a staff member resigned. The new director concluded that the NPO’s location—within premises rented by the FMG—was unsuitable, and relocated its headquarters nearby, adopting an in-house management model. Some FMG physicians, not consulted, felt alienated, and tensions deepened. The CISSS remained concerned about service duplication. Yet, signs of progress emerged. In spring 2023, a transparent meeting between the NPO and an FMG physician helped rebuild trust. The second NPO director had already improved relations with the CISSS through regular meetings. The third director addressed funding concerns and emphasized the need for partner support. This moment of vulnerability eased some tensions, though concerns about duplication persisted among clinical staff. Both parties remained committed to collaboration. With the family community organization, conflict resolution was facilitated by pre-existing relationships between the second NPO director, a board member, and the organization’s director. This led to open dialog and a collaborative agreement. While this organization became the main community partner, the NPO also built ties with others through meetings, mutual service presentations, and referral agreements.

A total of 14 factors were identified as significantly impacting intersectoral collaboration with the NPO. Table 2 provides a comprehensive overview of these factors and their effects, as well as the interrelationships among them. These factors were found to have both positive and negative effects on collaboration efforts. For instance, the quantity of human resources was shown to affect workload, motivation, general atmosphere, and service delivery both positively and negatively. It is important to note that several of these effects are also factors that have, in turn, an impact on collaboration. For instance, the degree of shared vision has been shown to affect the quality of communication and the level of trust, which are also factors that create other effects.

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Table 2.

Factors Influencing Collaboration and Their Effects.

Factors	Positive effects	Negative effects
1. Colocation	In-person, direct communication and collaboration Proximity to colleagues (enables relationships)	Discord/negative relationships Perception of organizational and personal interests Competition for power and resources
2. Level of vision sharing	Team spirit (internal + partnership) Good relationships Willingness to collaborate Clear roles, responsibilities, and framework Clear goals Trust Good/transparent communication Positive atmosphere	Division Bad relationships Competition Unclear roles, responsibilities, and framework Unclear goals Mistrust Bad/nebulous communication Negative atmosphere
3. Clarity of goals/missions	Clear roles, responsibilities, and framework Motivation Facilitation of collaboration Trust Positive relationships	Unclear roles, responsibilities, and framework Duplication of services (or fear of) Competition Mistrust Tensions/negative relationships
4. Interpersonal and inter-organizational trust level	Good/transparent communication Positive relationships Willingness to collaborate Positive atmosphere	Bad/Nebulous communication and apprehensiveness Negative relationships Reluctance to collaborate Negative atmosphere
5. Quality of relationships between individuals and organizations	Good/transparent communication Positive atmosphere Trust Motivation/commitment (affects human resources)	Bad communication/Unspoken words, backbiting, and confrontation Noxious atmosphere Mistrust Burn-out/resignation (affects human resources)
6. Clarity of roles, responsibilities, and framework	Motivation (for work and partnership) Clear service offering Focused energy Trust Good relationships	Frustration and confusion Unclear service offering Energy drain Mistrust Bad relationships/conflicts
7. Quality of communication	Transparency Positive relationships/Cohesion Positive atmosphere Clear goals Clear roles, responsibilities, and framework Trust	Nebulosity Negative relationships/ Passive-aggressive behavior Negative atmosphere Unclear goals Unclear roles, responsibilities, and framework Mistrust
8. Quantity of human resources	Correct workload Motivation Positive atmosphere Increasing the range of services	Overwork, burn-out, and resignation Demotivation Negative atmosphere Declining service offering Relationship, trust, and vision to be rebuilt with new employee/director/manager
9. Level of implementation and planning capacity	Trust Clear goals Clear roles, responsibilities, and framework Good management Positive leadership Satisfaction Motivation	Mistrust Unclear goals Unclear roles, responsibilities, and framework Poor management Weak leadership Dissatisfaction/frustration/stress Demotivation Work pressure
10. Level of knowledge and experience	Trust Implementation and planning skills Confidence Self-esteem	Distrust Struggle to implement and plan
11. Competition between partners	Clear goals Clear roles, responsibilities, and framework	Hinders collaboration Negative atmosphere Frustration Negative relationships Bad/Unclear communication/Backbiting Mistrust
12. Quality of leadership (by senior leaders)	Motivation Positive atmosphere Collaboration driver Good communication/Transparency Positive relationships Trust	Demotivation Negative atmosphere Competition Bad communication/Unspoken words, backbiting Negative relationships/Confrontation Distrust Frustration
13. Institutional and organizational context	Colocation and proximity Organizational and/or ministerial incentives for partnerships	Organizational slowness and demotivation Competition
14. Economic and social context (rural area)	Tight network/easy networking Understanding of local needs	Overlapping roles Bad communication/Unspoken words and backbiting

Bold text: Effects that are also factors influencing collaboration.

The degree of shared vision has been shown to influence several factors, including the clarity of goals; the clarity of roles, responsibilities, and frameworks; the propensity to collaborate or compete; interpersonal relationships; trust; and communication. It was an important factor with far-reaching effects that had a significant impact on collaboration. Arguably, this was the most salient factor underpinning all the collaborative efforts observed in the study. It was also identified as a fundamental condition for the quality of collaboration.

The level of trust has been shown to influence communication, relationships, atmosphere, and willingness to collaborate. Trust has been identified as a fundamental component of collaboration. Efforts to achieve healthy and effective collaboration are likely to be unsuccessful when trust is lacking, or distrust exists.

The quality of relationships has been shown to significantly impact communication quality, the general working atmosphere, trust levels, and motivation. Harmful relationships, the atmosphere they create, and a lack of recognition of others’ work have led to burnout and resignation. This phenomenon negatively affected the workload of the remaining staff and the quality-of-service delivery.

The development of personal and organizational relationships hinged on effective communication. The quality of this communication significantly impacted several areas, including trust levels, passive-aggressive attitudes, cross-sectoral cohesion, and the clarity of goals, roles, responsibilities, and frameworks. Building effective collaborations required clear, respectful, and transparent communication.

Clarity of goals significantly impacted the clarity of roles, responsibilities, and frameworks. It also raised concerns about the duplication of services, which could lead to a reduction in quality and cause customer confusion. This situation was not conducive to effective collaboration and could foster mistrust and competition.

The clarity of roles, responsibilities, and frameworks was found to significantly impact motivation levels. A lack of clarity had the potential to create a state of frustration and confusion. Additionally, these factors profoundly impacted the understanding of the service offering, which, in turn, could potentially lead to a state of mistrust. Finally, ambiguity was found to require significant energy from both staff and managers alike, as opposed to the focused energy observed when roles, responsibilities, and frameworks were clear.

Competition between partners has been shown to be detrimental. It fostered an unfavorable environment, created mistrust, and led to damaged relationships, ambiguous communication, and backbiting. Competition between individuals and organizations has been shown to undermine collaboration and hinder the achievement of collaborative goals. However, this factor has prompted leaders to define goals, roles, responsibilities, and frameworks more clearly.

Given the spatial and relational proximity of certain staff and the ministerial and organizational incentives to encourage collaboration, the institutional and organizational context had the potential to promote collaboration. However, the project’s implementation and the establishment of collaborations were characterized by slowness, which could be demotivating. Additionally, the context generated competition in service provision, hindering the practical implementation of collaborations.

Social and economic contexts positively influenced the quality of networking and the understanding of local needs. However, it has also encouraged overlapping roles in interpersonal relationships and the ambiguous communication that results from them. The participants offered nuanced perspectives on this rural context, viewing it as both advantageous and disadvantageous.

Discussion

To the best of our knowledge, this is the first case study to identify the factors that influence intersectoral collaboration between an NPO and its social and primary healthcare partners in a rural setting. This study fills a gap in the literature by providing an in-depth, context-sensitive understanding of collaboration dynamics in rural areas, an area that remains underexplored. ¹⁷ By highlighting the complexity and interdependence of these factors, our study contributes a more nuanced perspective that complements and extends previous research. Conducting this study through fieldwork enabled us to capture the evolving nature of collaboration in real time, offering rare empirical insights into how partnerships are formed and sustained in practice. Ultimately, the collaborative efforts of all parties involved led to the formation of collaborative relationships. However, the process was not without its challenges. Several factors influenced the establishment and implementation of these collaborations.

Our research shows that a shared vision is essential for effective collaboration. To ensure a productive partnership, those involved must first agree on their overall goals and establish overarching principles that will guide them toward achieving those goals. Mutual understanding is key to effective collaboration. This vision is complemented by more specific goals, roles, responsibilities, and frameworks. However, establishing a clear understanding of the desired outcomes and how to achieve them is fundamental to initiating a collaborative partnership.

Other studies have emphasized the importance of a shared vision in collaborative endeavors. Alderwick et al’s ¹⁷ systematic review of reviews supports this, noting that a shared vision is often identified as a key factor in successful collaborations. Reiter et al ³⁴ similarly caution that mistrust may arise when parties lack a mutual understanding of the project’s vision, particularly if differences are not openly discussed during meetings. They stressed the importance of transparent communication to address these discrepancies and foster alignment.

Tsasis’s study of interorganizational collaboration among NPOs ³⁵ also highlights that the absence of a shared vision can lead to competition, especially when collaborators are perceived as overstepping their roles. Tsasis argues that a clearly articulated vision, combined with well-defined roles and complementary goals, supports effective and nonduplicative collaboration. Our findings reinforce and extend these insights by showing how the rural context amplifies the need for trust-building and clarity of vision, given the limited resources and overlapping roles of local actors. We observed that when roles and goals are poorly defined, even well-intentioned collaboration can result in perceived duplication and friction. Conversely, when partners engage in open dialog to clarify and align their visions, collaboration becomes more cohesive and resilient.

The quality of interpersonal and interorganizational relationships also played a significant role in establishing the collaborations observed in our study. Alderwick et al ¹⁷ acknowledged the central role of this factor in determining the likelihood of successful collaboration. Among other things, Alderwick et al ¹⁷ discussed the impact of relationship history on collaborative efforts, a phenomenon we observed among collaborators. However, our study goes further by examining how these relationships unfold in the context of rural communities, where actors often occupy overlapping roles. To the best of our knowledge, our study is the only one to address the complexity and implications of overlapping roles, which are more common in rural settings, and their impact on intersectoral collaboration.

Trust and communication are widely recognized as foundational to effective collaboration. van Vooren et al ³⁶ observed that prior working relationships help establish trust, while Steenkamer et al ³⁷ noted that their absence can impede intersectoral efforts. Our findings echo these insights, showing that in rural contexts, dense and familiar networks can both support and complicate trust-building, particularly when roles overlap and resources are limited.

Trust influences multiple dimensions of collaborative work,^{17,18,34 -36,38 -40} and its development is closely tied to the quality of communication. As Alderwick et al ¹⁷ and Reiter et al ³⁴ have shown, open, frequent, and transparent exchanges foster mutual understanding and strengthen relationships. Our study confirms these findings and adds that in rural settings, where informal communication channels are often as influential as formal ones, the tone and frequency of exchanges can shape perceptions of legitimacy and value.

Clarity around roles and goals is also essential. van Vooren et al ³⁶ emphasized the importance of articulating these elements early in the process. In our case, uncertainty surrounding the NPO’s mandate created barriers to trust and collaboration, with concerns about service duplication delaying joint initiatives. Ultimately, our findings suggest that respectful, transparent communication is key to resolving tensions and enabling meaningful collaboration.

Limitations

This is a single case study conducted in a well-defined rural area in southern Quebec. Its findings may not be applicable to other regions of Quebec, Canada, or elsewhere in the world. However, several international studies have identified similar influential factors.^{17,34 -40} Some participants with professional experience outside the studied region also noted that the challenges they faced were not unique, suggesting that conflicts can emerge in any context where strong-willed leaders are present. It is important to acknowledge that the interviews took place during a period of significant interpersonal discord among individuals representing different organizations. The intensity of respondents’ emotions may have shaped their answers, and conducting the interviews at another time might have yielded more neutral or reflective responses. Finally, it is worth noting that only one interview was conducted with a man, and the rest were with women. Including a broader range of male perspectives could have enriched the analysis.

Conclusion

Intersectoral collaboration has been identified as an effective strategy for providing integrated care to vulnerable and populations with complex needs. Although such collaborations can positively impact the health of local communities, their implementation requires a shared vision, strong relationships, and transparent and respectful communication. Our study offers practical insights for rural healthcare project leaders, helping them anticipate and navigate common challenges to enhance the success of their collaborative initiatives. Further research is needed to deepen our understanding of intersectoral collaboration in rural contexts. Such research will contribute to a more comprehensive understanding of the unique characteristics and contextual factors that shape collaboration in these settings.