Table 2 Perceived barriers to synergies

Factors Outside the SRAP

   Turf issues and politics

"Health care in [our state] is pretty 'turfy.' When we became the lead agency... it changed a lot of interpersonal dynamics. It created huge jealousies in the state and caused many problems."

"I guess, I felt like there were more opportunities that could have been pursued with the Office of XX... actually what happened was they sort of sat on it and didn't really do anything with it and sort of said it would be threatening to certain people. And it was probably the turf issues."

"Politics and egos."

   Differences among organizations' types, structures and agendas

"The one dynamic that probably interfered with synergy a little bit is the nature of our different work environments. I come from a private not-for-profit and [our] issues are very different... than those programs based in academia or health departments of state governments. I struggle with very different issues and sometimes there was really a lack of understanding about the different environments we each come from."

"I think some factors [that kept synergies from developing] are in that the infrastructure at some of these health professional schools generally didn't have the same type of vision for moving in that direction as far as entrance into the schools [for minorities].

   Racial and cultural differences in perspectives; racial tensions

"The other thing that we noticed that was very unfortunate is that these [coalitions] tend to form along racial lines. There will be a black health care coalition and a white health care coalition, and they won't talk to one another. We, even though we tried, were never successfully able to get those folks to break bread together. That was a failure that was disappointing."

Features of the SRAP

   NPO was sometimes over- involved or under-involved in managing collaborations

   "Something that just made it worse was national program staff inserting themselves in the middle of it when they didn't really have a full understanding of the dynamics."

"I think the SRAP program office could have intervened in states where they knew things were not going well and said, 'You either take this and this and do with it as we say because we have the money. You need to do it, or you need to find somebody else to lead the program."'

   Too few program dollars to promote or maintain synergies

"The folks that early on I was engaged with, for the most part, stayed involved to the end of the project. [But] towards the end of the project, it's fair to say as folks weren't receiving funding, some would miss a meeting here or there, and that just happens. You have to go on to other projects or go on to other things that take your time."

   Limiting program involvement to only some counties within states

"You know, Robert Wood Johnson made the decision in Phase II to concentrate their efforts. I'm not sure that really proved to be as beneficial as people thought it would be. In other words, the layering on of different services in an area was not as beneficial as it could have been or as they anticipated it would be."

"It was almost like a betrayal later on when I went to a meeting of the [my state] Southern Rural Access and was told that the decision was made to drop everyone that wasn't in the Delta. We were dropped!... I guess that's my point that I want to stress to folks is you almost hang people out to dry."

"Well, one of our problems is in Texas we were not a statewide project. We really tried hard to bring some of the programs to the statewide level and to get the support from state agencies, and things were a challenge because we were regional."