Texas Health Institute was one of seven national finalists to receive a grant from Robert Wood Johnson Foundation’s (RWJF) to test their Aligning Sectors Theory of Change. Over the course of two years, THI examined 20 cross-sector initiatives, varying in geography, scope, and size, from across Texas. We share our findings on the new Align Texas website, which includes our blueprint report and full length report

Cross-sector collaborations have become an increasingly popular approach to address social challenges and inequities. These collaborations often involve organizations from health care, public health, and social service sectors, with each organization contributing unique strengths and perspectives. Cross-sector collaboration can lead to stronger, more sustainable improvements to population and community health.

“In Texas, we have a unique learning opportunity,” says Ankit Sanghavi, MPH, BDS, executive director of Texas Health Institute. “Given the breadth and scale of collaborative efforts operating here, and the variety in places, populations, and health statuses combined with political and other contexts, our team was able to study several cross-sector alignment efforts for achieving health equity.”


The RWJF Aligning Sectors Theory of Change describes this process of cross-sector collaboration, including the areas in which change occurs and the elements involved in the process (see below). When we started, the RWJF theory of cross-sector alignment had yet to be evaluated to understand in more detail how alignment works and under what circumstances. 

A diagram showing three inputs (public health, health care, social services) going into a sideways bottle that contains gears labeled shared purpose, data, governance, and financing, and arrows along the gears labeled community voices, equity, power dynamics, and trust. The neck of the bottle ends in "changes in: mindsets, practice, policy" and "shared progress toward: communities' goals and needs, health equity, racial equity."

THI applied a “realist” evaluation framework in order to understand the specific ways in which cross-sector collaboration progressed for these coalitions under various conditions. A realist evaluation framework seeks to identify the specific changes that happen because of an activity, as well as contexts in which change occurs and the means by which it happens.

Emily Peterson Johnson, LMSW, senior health research analyst on the project reflects that “realist evaluation theory offers an exciting way to make evaluation findings more meaningful, actionable, and generalizable.” A realist evaluation can give us a more nuanced understanding of how, why, and in what contexts cross-sector collaborations happen.


A map of Texas with 20 labeled coalitions. For full list in accessible map, visit aligntexas.texashealthinstitute.org.

Guided by a statewide steering committee representing various organizations, THI conducted:

  • An environmental scan of health equity-focused cross-sector initiatives in Texas
  • Key informant interviews with leaders from the leading organizations of the 20 initiatives
  • An online survey completed by over 200 leaders from the selected cross-sector initiatives
  • Focus groups with 136 participants from five communities with well-advanced cross-sector initiatives

Site Selection of Twenty Health Equity Focused Cross-Sector Alignment Efforts Across Texas

“This project has illuminated the truly amazing work well underway by outstanding community organizations,” says Cody Price, MPH, health policy research analyst at Texas Health Institute. “The coalitions and community organizers we spoke with consistently referenced the value of trust with their community members. There’s a lot of work left to be done, but working together is the best path forward. And in our digital age, we may have better tools to connect various stakeholders.”

This project spanned over two years and involved input from a variety of THI staff, external consultants, advisors, and partners. As our team looks back on this undertaking, we found many points of learning and growth throughout the process.


We learned about the value of realist evaluation theory. While many traditional evaluation frameworks can describe program activities or outcomes at a basic level, the realist evaluation approach provides a greater insight into why things work. This can help us understand how to replicate similar outcomes.

We learned about how to adapt the project to changing needs of participants. As with many projects that launched at the beginning of the COVID-19 pandemic, we had to adapt our plans. We learned about being flexible and sensitive to the needs of participating organizations, many of whom were often on the frontlines of pandemic response.

We learned about the value of these findings. To our knowledge, a large-scale assessment of cross-sector alignment efforts has not previously been conducted within Texas or nationwide. Our findings offer valuable information for initiatives that want to learn about the processes by which alignment happens, best practices for alignment, and common barriers.

“This evaluation taught us about the foundational role that trust and community voice play in effectively bringing together communities,” says Afrida Faria, MPH, manager of health equity programs at Texas Health Institute. Without uplifting the voice of the community, especially those historically marginalized, communities cannot work towards meeting the true needs of its members.”  

THI looks forward to working with RWJF and the Georgia Health Policy Center to disseminate these findings and apply them in ongoing work aimed at leveraging cross-sector collaboration to address health inequities.