Locating Power in a Cross‐Sectoral Health Promotion Collaboration Addressing HIV and Hepatitis C

ABSTRACT

Issue Addressed

Power is central to understanding how health promotion networks and collaborations function. Power underpins the relational connectivity, yet its complexity renders it difficult to define. This study explores how power is understood within a health promotion network addressing HIV and Hepatitis C in Victoria, Australia.

Methods

Inductive interviews were conducted with 30 senior organisational members working in the HIV and Hepatitis C health sector in Victoria, Australia. Participating organisations included community, research, government and health organisations. Interviews were coded in NVivo using an inductive approach, underpinned by a phenomenological framework.

Results

Five themes were identified: multiple dimensions of funding; collaboration and relationships as power; organisations as champions or gatekeepers; the role of evidence in defining the sector; and the role of advocacy in the sector. The different and recognised power mechanisms, through which each part of the sector could have influence, were a valued characteristic of the response.

Conclusion

The Victorian HIV and HCV network provides a useful insight into the multiple forms of power within a health promotion network, and how these forms of power helped balance aspects of the power asymmetries in the network. This research indicates the need to consider power in multiple, potentially balancing dimensions when developing policies to strengthen collaborative health promotion practice.

So What?

Understanding the value of multiple forms of power within long‐term networks may help strengthen cultures, values, and policies that ensure power dynamics enhance, rather than limit, collaborative practice.

1. Introduction

Cross‐sectoral networks and collaborations are a widely adopted strategy for health promotion [1, 2]. It has long been argued that collaborative approaches are needed to address complex social and public health challenges and systemic inequities [3, 4, 5, 6, 7] especially those with multiple causal factors, such as the prevention of infectious diseases like HIV and Hepatitis C [8]. Recent studies highlight how stronger integrative relationships between health promotion and health and social services can improve outcomes [1, 9, 10].

Despite its many benefits, cross‐sector health promotion collaboration faces persistent implementation challenges—including limited resources, governance complexity, and accountability gaps—but one of the most underexamined and structurally embedded barriers is the disparity in power between organisations [11, 12]. Power not only shapes access to decision‐making and resources but also influences relational dynamics such as trust, legitimacy, and role recognition, which are foundational to collaborative practice [3, 13, 14]. Relationally oriented theories of collaboration emphasise that collaboration is not merely about aligning tasks or exchanging information (as with coordination), but about cultivating shared meaning, mutual commitment, and joint ownership across organisational boundaries. While coordination frameworks focus on operational alignment, collaboration demands deeper relational engagement and the capacity to navigate difference, ambiguity and interdependence [6, 15, 16]. Huxham's theory of collaborative advantage explicitly identifies power as a central tension in collaborative settings, often experienced as both a source of pain and potential [17].

Seminal work by Grey [3] positions collaboration as the ‘constructive management of differences’, arguing that power and politics are intrinsic to the collaborative process and must be deliberately addressed to avoid reinforcing inequities. Klijn and Koppenjan [18, 19] extend this view within the governance network tradition, emphasising that collaboration in policy networks involves strategic interaction among interdependent actors with divergent interests, bounded by institutional constraints and shaped by power asymmetries. Their work highlights that power is not only relational but also institutional and strategic, affecting whose interests are represented, whose knowledge is legitimised, and whose preferences shape outcomes.

Despite these insights, power remains under‐theorised in much of the collaboration literature. Scholars including Lotia [20], Trif et al. [21], Kȁhknönen [22] and Stout and Keast [15] have noted that mainstream frameworks often treat collaboration as a neutral or technical process, overlooking how power dynamics shape learning, participation and decision‐making. This gap underscores the need to treat power not as a background condition but as a central challenge in collaborative practice, especially in cross‐sectoral networks where organisational asymmetries are structural, enduring, and often relationally corrosive.

This article provides perspectives of power in a long‐standing inter‐organisational collaborative network: where power is located in the collaboration, how it is used, and how it impacts goals and processes of the organisations involved, individually and as a collective. The study focuses on a health promotion network addressing HIV and Hepatitis C in Victoria, during a time when organisations in the sector were responding to the most significant changes to the prevention, treatment and policy landscape in 20 years. This period was characterised by rapid advances in biomedical prevention and treatment, alongside substantial shifts in policy and funding arrangements, fundamentally altering how HIV and hepatitis C prevention and care were delivered in Victoria.

1.1. Cross‐Sectoral Collaboration and Power

Power is a challenging concept to define, due in part to its ubiquity in all aspects of society. There is an extensive body of debate elucidating the nature of power, its origins and uses. For example, Weber [23] framed power as the possibility of achieving one's goals, even in the face of resistance from others. Arendt [24, 25] proposed a more collectivist positioning of power, arguing that power is created through consensus and collective action. Dahl [26] contested the idea that power was centralised in the hands of an elite, arguing for a pluralistic view of power unequally distributed across society. Lukes [27] argued for multi‐dimensional views of power, inclusive of preventing choices or decisions from being made, and influencing beliefs to align with one's interests, even when those beliefs are anti‐thetical to their best interests. Foucault [28, 29] argued that power was ubiquitous, and operated through all aspects of society, including social norms, language, and institutions, all of which served as a means of societal control. Keeping track of these conceptualisations, their critiques, and their intersections adds to the complexity of the discussion around power.

Power is multifaceted and can be found in the differences between individual organisations, the nature, structure, and quality of relationships, or the alignment of goals and visions across the network of organisations. While traditional theories of power often focus on domination, control, or resource dependency, a more nuanced typology is particularly relevant to understanding power in collaborative and networked settings. This typology—power over, power to, and power with—offers an alternative lens for examining how power operates relationally and structurally within cross‐sectoral networks and collaborations (or collaborative networks) [11, 15, 16, 30, 31].

Power over refers to hierarchical and coercive forms of power, where one actor imposes its will over another, often through control of resources, decision‐making authority, or institutional legitimacy. This form of power aligns with Weberian and Dahlian traditions, emphasising asymmetry and resistance [23, 26]. In collaborative contexts, power over can manifest through dominant organisations shaping agendas or marginalising less‐resourced partners [11, 16, 30, 31].

Power to captures the capacity of actors to act and effect change. It reflects agency and the ability to mobilise resources, knowledge, or relationships to achieve goals. This form of power is generative rather than coercive and is often linked to innovation and problem‐solving within networks [30, 31]. In collaborative governance, power to is critical for enabling actors to contribute meaningfully, especially when navigating complex, multi‐causal issues like public health or homelessness.

Power with refers to the collective and relational dimension of power—emerging through shared purpose, mutual respect and joint action. It is grounded in collaboration itself, where power is co‐created through trust‐based relationships and shared decision‐making [15, 17, 32]. This form of power is particularly important in cross‐sectoral networks and collaborations, where co‐dependent outcomes depend on the ability of diverse actors to work together across institutional boundaries.

This tripartite framework challenges the notion that power is inherently antagonistic or zero‐sum. Instead, it highlights how different forms of power can coexist and interact within collaborative settings. As Stout and Keast [15] argue, recognising and intentionally cultivating power with can transform traditional power dynamics and foster more equitable and resilient collaborations. Agranoff and Kolpakou [31] and Prysmakova‐Rivera [30] similarly contend that effective collaboration requires moving beyond hierarchical control towards distributed agency and relational empowerment.

Importantly, this differentiation also addresses a gap in the literature. Table 1 provides an analytic framework using the tripartite power concepts—power over, power to and power with—to examine the interorganisational networks in the HIV and Hepatitis C fields and further understanding of how authority, agency, and collaboration shape network dynamics, resource flows and equity outcomes. By foregrounding power over, power to, and power with, scholars and practitioners can better diagnose asymmetries, design inclusive governance structures, and support collaborative processes that are both effective and just.

TABLE 1.

Tripartite power analytic framework.

Power concept	Definition in HIV context	Key indicators
Power over	Control exerted by dominant actors (e.g., funders, government agencies) over resources, agendas, or marginalised populations	Funding gatekeeping, policy mandates, exclusionary practices, that is who makes decisions, sets priorities
Power to	Capacity of actors to initiate change, innovate, or deliver services effectively	Organisational autonomy, innovation capacity, and service provision reach, that is, internal enabling processes
Power with	Collective capacity built through partnerships, coalitions, or community engagement	Inter‐organisational collaboration, co‐designed programs, and peer networks, how do they actually work together

2. Methods

This study is part of a larger study examining the relationships of organisations involved in the prevention and treatment of HIV and HCV in Victoria, Australia. Victoria is the second‐largest state, home to 6.5 million people as of 2021 [33] with both State and Federal governments providing funds for health research and community‐based services. Ethics approval has been obtained from UNSW's Human Research Ethics Committee (approval HC210686) and Thorne Harbour Health's Research Endorsement Panel (approval CREP/THH:22‐001).

2.1. Context: The Victorian Partnership

In the early years of the HIV pandemic, Australia's affected communities, including gay and bisexual men, people who used drugs, and sex workers, had a significant role in advocating how government and health services responded [34]. Community organisations established by affected communities collaborated with health services and governments, working together to create effective strategies aimed at communicating health information to the affected communities and increasing awareness more broadly in Australia. The relationships that formed between agencies and organisations have evolved over time [8] and, to some extent, have been replicated by organisations working to address other blood‐borne viruses and sexually transmitted infections, including hepatitis C (HCV).

The availability of clinical interventions for prevention led to bold Australian and Victorian targets for the virtual elimination of HIV and HCV as public health threats, including the elimination of HIV and HCV transmission by 2030 [35, 36, 37] and significant practice shifts put in place [38, 39, 40]. However, the sector still had considerable challenges to overcome. Past separation of treatment versus prevention, of community versus health services, and of peer educators versus clinicians was being disrupted by the introduction of treatment as prevention, potentially changing interorganisational relationships and power dynamics. Stigma and discrimination continued to be major issues, impacting the uptake of treatment [41, 42].

While well‐connected communities, such as Australian‐born gay men and sex workers, had seen relatively low levels of infection rates compared to other OECD countries [43], other communities were not taking up treatment as quickly, and there were multiple barriers to engaging, including considerable distrust of government and clinical services based on past experiences [44, 45]. Moreover, resources within the HIV and HCV sector, including funding, were under significant pressure. With these complexities, the sector then entered the challenging years of the COVID pandemic, navigating its impact at a structural and community level.

2.2. Data and Analytic Approach

Data consist of qualitative interviews with key informants from community, research, government and health organisations. Participating organisations were identified through consultation with a reference group drawn from peak organisations in community health, policy, government, research and clinical service delivery. Forty‐four organisations of different sizes and organisational focus were approached to provide multiple perspectives, including policy development, funding and direct health or community services.

Of the 22 organisations that took part, 16 were based in Victoria with six national organisations located in Sydney and Canberra but active in Victoria. Informants were recruited via email, either directly using publicly available contact details or by referral from the participating organisations. In total, 30 individuals participated in one‐on‐one interviews conducted over audio‐recorded video call between December 2021 and January 2023. The interviewees were a mixture of high‐ranking bureaucrats in the public service, clinicians working in the public health sector with a particular interest in blood‐borne viruses, CEOs and Executive Directors of community‐based and peer‐led organisations, and internationally renowned researchers from universities and research centres.

Interviews were guided by semi‐structured questions focusing on experiences and involvement with other organisations in the sector, views on upcoming opportunities and challenges for HIV and HCV treatment and prevention, and specific organisational priorities. Respondents were asked directly ‘Where do you see the power in the network?’ The question was left open‐ended to leave the interpretation of ‘power’ up to the respondent. Interviews ranged from 35 to 86 min (average of 56 min) and resulted in 27 h 56 min of transcribed text.

Interviews were imported into NVivo and coded using an inductive open coding approach. Codes were then systematically examined and interpreted through thematic analysis to develop patterns across the dataset [46]. Two researchers independently coded interviews, and the coding schema was cross‐checked and reviewed by a third researcher distant from the initial analysis. The analysis used an inductive approach, underpinned by a phenomenological framework, seeking to understand the social reality of the HIV and HCV sector from the viewpoint of those embedded in it [47].

3. Results

3.1. The Multiple Dimensions of Funding

Twelve respondents indicated that funding, and the government (or Department of Health) as the primary funder in the sector, were key to understanding power, making it the most frequently nominated theme. In a sector where funding is largely provided by State and Federal governments, nominating government and funding as sources of power was expected. The ability to fund an organisation or program, or not, has an enormous impact on what occurs within the sector:

I think power comes from money… if it's the power to make things happen, it's the government, the government has the power. (Health service)

The HIV and HCV sector has a long history of volunteering and community engagement, but money is still an important driver of action and behaviour. While the Victorian Department of Health was the largest funder, there were other sources, such as philanthropic institutions, that were described as potentially providing a level of independence. The ability to fund a program or body of work, or have access to funding, necessarily entailed a degree of influence.

I think to me power's money largely, so I see that—but I also think that the Department of Health as I mentioned has situated themselves to be the decision makers in the workload of other services quite significantly. So, it largely lies with them but when [an organisation] can get money from [philanthropic] external organisations … that allowed them a whole heap of autonomy to influence or develop a program that aligned with their approaches and so forth. (Research organisation)

However, in all discussions around funding as a source of power, there was recognition from the participants that there were more forms of power that need to be accounted for. Having the power to ‘make things happen’ in the sector required more than just money:

I always say Foucault can be summed up in one sentence, power comes from everywhere… So yes government holds the purse strings but in order to be able to function and to be able to do the work that government needs to do… they have to work with others and none of this can really work without community. If a community is hostile, antagonistic, then everything just falls apart really. (Research organisation)

The case for funding and government as a source of power is more focused on the difficulty in achieving the sector goals without funding and government support. Funding could be considered a prerequisite for achieving many of the sector's goals, but it was not considered by itself to be the only source of power.

There's so much potential but without adequate resourcing it's sort of dormant power or it's just not there. So the power ultimately goes to those organisations who … can attract more and more funding by diversifying their offerings and saying yeah we can do this and we can do that. (Community/Peer Organisation)

The interviews demonstrated that the power within the funding regime was seen as multidimensional—there was power in being able to choose who would be funded (power over), power in successfully competing for or having funding for a program (power to), and there was power in community mobilisation or support being an enabler to other forms of power (power with).

3.2. Collaboration and Relationships as Power

The relationships between organisations were nearly universally rated as being critically important to all organisations of respondents, vital to their ability to function within the sector. There was widespread recognition that no organisation in the sector was capable of addressing the multitude of systemic issues alone, as encapsulated in the following statement:

I think the network is the power and I think together we are much stronger than the sum of the parts or the individual groups or whatever within them. (Research Centre)

The mechanisms behind how the network could be used illustrated their understanding of the power in the network. Organisations with less capacity to directly engage with the broader sector were able to use their relationships to ensure that they, and the communities they worked with, were not overlooked:

The power is having organisations that get opportunities that you wouldn't necessarily be able to access yourself, and them leveraging those opportunities to support the other organisations in the network, or to raise issues in forums that the other organisations don't get access to, or opening doors and ensuring that we are at the table when otherwise we wouldn't have been invited, and raising our issues, but in a way that's respectful of our autonomy, and not speaking on behalf of us, but ensuring even though we're not there, our voice is still heard. (Community/Peer Organisation)

Given the histories of stigma and discrimination for many of the communities affected by HIV and HCV, the community and peer organisations were very protective of their voice. It was a measure of the high levels of trust in the network relationships that peer‐led and community‐based organisations described a level of confidence that their interests would be respectfully represented by others in their network.

Respondents also discussed the ways in which bringing together a diverse set of communities and interests collectively allowed for the development of mutually beneficial values and norms—that is the development of relational or collective power.

I think the power in the networks is actually being able to share the information and being able to produce a clear picture of how collectively we can have an impact. If it's individuals going and lobbying to government, there's lots of little pockets of money given out here, there and everywhere… the accountability is to go, ‘How do we achieve the best outcome?’ and it's not by having duplication or complications for government, it's about being able to present that clear picture. I think the power in this space is to be able to actually get that more collective view with some or all of the groups in that space working together to be able to present that one clear plan. (Community/Peer Organisation)

The importance of the relationships in the sector was partly attributed to how they had endured over decades, and the benefits this conferred.

The powers are in the relationships… I mean it's in us having different perspectives and experience, different ideas with a common purpose. I guess the tenacity and the persistence to hold to that over a long period of time and to take the long view. Also, to say these conversations that we have this year will bear fruit in 5 years' time, and 10 years' time and that if we build a strong foundation of relationships… we can then face challenges in the future which we can't imagine today. (Community/Peer Organisation)

Eliminating HIV and HCV is a complex task, with many barriers that need to be overcome, both internal and external to the sector. The ability to collaborate and focus the efforts of the many parts of the sector on issues is widely seen as a strength, a locus of collective power, both for present and future endeavours.

I think that the network itself is very powerful. The fact that it is interconnected, I think it's both the strength and the kind of weakness. I think the weakness is that you pull part of it out and it starts to [unravel] – you know because it's reliant [on those connections]. I think the power is in the collective but it's all connected. I think that's what makes it powerful, it's not about any individual player, it's not about one person, it's not about one organisation, it's about the kind of collective network that's together pushing for it. Within the shared mission there's different views and I'm not saying there's not diversity and all that kind of stuff, but overall people are working towards the same goal, which is really I think also very powerful. (Community/Peer Organisation)

The organisations in the sector are all working towards the elimination of HCV and/or HIV, but have distinct areas of expertise, approach, influence and community connections. Participants described their ability to work collaboratively in identifying how the ‘sum of their parts’ can have the best outcome is far more effective than if each individual organisation worked in their own interests.

Some respondents were able to indicate examples of this type of behaviour from their partners, but it was not a universal experience. The ‘power with’ here is a quality of the collective, arising from an experience of trust, and the ability of the organisations to work together successfully and align their purposes, despite the plurality of opinions and experiences.

3.3. Organisations as Champions or Gatekeepers

Community organisations in the sector have histories of being well‐connected to, and trusted by, the communities most impacted by HIV and HCV. These community organisations often have significant numbers of peers from the communities working and leading them. While large community organisations are important foci for the relationships in the sector, several respondents referred to them as holding a gatekeeping role, particularly with the communities they represent.

I think community organisations, especially… ones that have become very large organisations, do have a lot of power, yeah, in the way things are framed and the way that [they influence when] certain things are allowed to be discussed or not discussed. (Research Centre)

The National and State community organisations were recognised as advocating for and even directing programs and research towards priority issues for their communities, and used their power to endorse or shape programs and research. This included navigating competing views, perspectives or interests.

Yeah, that's put me in an awkward position occasionally where I've gone, I work quite closely with the [National community orgs] and some of the State players in HIV and LGBTQ health are actually impeding the [National community Org] from tendering, from engaging in education and health promotion because they see it as competition for money that they believe that they're better placed to get. So there's definitely competition and there's power, and the way some of these networks function… it doesn't look like quite as collaborative as it could from the outside. (Research Centre)

The power of organisations in the sector is asymmetric, and while the majority view of respondents was that the sector intends to be collaborative, there were competing interests to be navigated. Large community organisations were seen as an example where individual organisations could still have the ‘power to’ significantly influence outcomes when they see it as being to their or their community's benefit.

3.4. The Role of Evidence in Defining the Sector

The issues around preventing and treating HIV and HCV are complex; having solid evidence was seen as providing clarity and direction to organisations who were having to find the best use of limited resources. Respondents from all types of organisations in the sector (government, health, community based, peer led and research) recognised evidence as spanning clinical, epidemiology, research, and lived experience, and discussed the importance or power of evidence in relation to the programs they delivered and their planning for the future. Evidence also provided legitimacy in responding to those who might question choices and decisions made but were able to see the research and evidence that backed the decision.

I think the power is in the sector having research backup, having our sector telling us where gaps are, and then how we can best act. You know, if the [research centre] tells me ‘This is the evidence, this is what I think we should do. Back it up with cost effectiveness work’, I can take that to a Minister and say ‘It's going to cost this much to do this and we should do this’, but without that I feel I don't have the power. (Government)

This was important not just for government backing up decisions, but for community and community organisations, who needed to trust that the actions of the sector reflected their best interests. One of the ways the sector maintained this trust, as described by respondents, was the recognition that the lived and living experience of peers provided valuable evidence and insights alongside clinical and research evidence, especially in how to engage with affected communities:

I do think the power is the community response, the community voice, because you don't get to treat all those hard‐to‐reach communities without community involvement and community voice and peer‐led and all those elements. I think that's been successful in HIV response, and I think similarly trying to work towards HCV and work towards HBV as well. (Community/Peer Organisation)

However, the power of evidence, and how that power was applied, was not uncontested:

The clinicians and the epidemiologists and the modellers are very powerful. And modelling, I think, has become its own powerful thing in the last 10 years or so. So there was a bit of modelling work… that said, ‘If you double the distribution of needles out of NSPs, you'll halve infections.’ So that totally turned policy for a while, so disinvestment in kind of educated, trained NSP staff and a priority on pumping needles out the door…

And guess what? Needle distribution went up and infections didn't go down. So, modelling is interesting, but it isn't always right, let alone perfect. So, yes, you do need people who are trained, empathic, can work with someone where they're at. (Research Centre)

Participants described evidence coming from medical/epidemiological studies, social research, and the lived and living experience of communities and individuals living with HIV or HCV. Power in this form was not tied to the organisations themselves, but to the organisations' power to draw on of evidence to plan, persuade and legitimise their actions. However the validity afforded to multiple forms of evidence was positioned as a balancing effect to individual forms of evidence.

3.5. The Role of Advocacy in the Sector

A significant activity for community organisations at both the National and State level was advocating for the needs of affected communities. Historically, the early successes in Australia's HIV prevention owed a great deal to the ability of affected communities to organise and advocate effectively [34]. This advocacy work has brought attention to the need for funding to the sector and the need to listen to the voices of those affected by HIV and HCV to shape policy and programs that address their needs respectfully.

The power of the peer is key. So when you have an HIV intervention or HIV research project or something if it's irrelevant to [HIV] positive people, they won't care about it and they won't engage with it… a good example is even with prescriptions, when doctors prescribe, if you want to know what tablet you should take, then positive people say, go and see your doctor. But if you want to know how to take it over the course of 40 years to make sure that you still have a decent quality of life, you can only talk to a positive person about that… we want those interventions to be successful, and they're more likely to be successful with positive people engaged. So there's something in there as well about the power of the network being the power of peers… because it makes our HIV response in Australia successful … And that's because positive people are engaged at the table at all levels of the response, right the way up to the tables in Canberra [national capital]. (Community/Peer Organisation)

The ability of the affected communities to be heard was described as especially important for government. The advocacy work was seen to challenge the status quo and could drive innovation, and helped the system to respond to the needs of the community.

HIV is 100 per cent, it is the advocacy of the [peer and community organisation]. To me, that's where the power sits because often we will be having discussions [about significant policy reforms], we've got a view but we know the sector will be very, very vocal about it. So in that sense, I do see the sector does have quite a bit of power. (Government)

The power is vested with the service system in terms of community engagement and voice leadership authorisation which is very different from the government position… we're not micro‐managing the shape of an intervention that's determined by the different players within the service system, independent to government. In order for government to shift there has to be power in the community sector and in the service system advocacy power so they can have the hard conversations with [government] ministers about funding or about health issues. I do see it as distributed… each agency has its score of power. I've seen that activated time and again effectively. Very effectively. (Government)

Advocacy here is seen as a key characteristic of the sector relationships. For example—the power of the community organisations or health services to influence the overall sector due to their insights and perspective is an example of ‘power to’, where insights and advocacy are recognised, even supported, by the collective sector as a check and balance to the ‘power over’ of government and funding.

4. Discussion

The framing of the question about power in the network was left purposefully open‐ended, allowing participants to expand upon it in a way that made sense to them. While the resulting themes drew parallels with theories of power, they were not confined by specific theoretical paradigms. While participants identified power asymmetries in the system, such as those around funding or large organisations, there were also themes that identified that the relationships between the organisations were a strength of the system, and the differences between the organisations were seen as enhancing the effectiveness of the response to HIV and HCV. The overall picture drawn by the respondents was of a system in which the organisations were simultaneously collaborating and competing. Three major points that arise from the analysis.

First, the themes discussed by the respondents were reflective of the history of the sector, in particular the ways in which the organisations have seen success in addressing the social and systemic issues related to treatment and prevention of HIV and HCV [8, 34, 48]. The Australian response to the AIDS epidemic in the 1980s and 1990s centred on the emergence of strong community organisations embedded in sustained relationships with government and health agencies. While the network has undoubtedly evolved over the decades, many of the community organisations and the relationships formed in the early years are present in some form. Advocacy and the willingness of government to engage with advocates were a substantial part of the early sector's successes and have consistently been a part of the sector's activities. Early efforts at health promotion were based on the best available evidence, and as evidence grew, the health promotion efforts adapted to incorporate them. All these efforts led to Australia's efforts at treating and preventing HIV and HCV being among the world's most successful with rapid treatment scale‐up, high cure rates, and significant reductions in new infections [49, 50].

Second, in much of the discussion on power, it was not solely located in an individual or an organisation or treated as a quality or attribute of an individual. Rather, power was embedded in the principles of how the sector worked together, through the use of advocacy and evidence in achieving collective goals. These principles were seen as an integral part of how the sector worked, to the extent that they have been formalised in the State and National Strategies on HIV [35, 36] and HCV [37, 51]. Principle 9 of both National strategies, ‘Commitment to evidence‐based policy and programs’, and Principle 5, ‘Prevention’, both make explicit reference to the use of evidence‐based approaches. Similarly, Principle 1, ‘Centrality of people with HIV and meaningful involvement of priority populations,’ Principle 4, ‘Health promotion’, and Principle 10, ‘Partnership’, all reference the importance of valuing the participation and dialogue with affected communities to ensure their needs are met.

Third, the multiple overlapping domains of power were present simultaneously. Arguably, these domains are interdependent on each other. Each part of the sector had different and recognised power mechanisms through which they could have influence. National and State community organisations are significant actors in the sector, but other organisations are able to have considerable influence through their connections to and with the network. Funding is important for ensuring that the sector functions, but evidence was described as being used to underpin what gets funded. The consequence of these multiple interacting forms of power is that there is more than one avenue to achieve an outcome. This has been reflected in other studies of the policy influence of peer organisations within the HIV and HCV sectors, where multiple levers can be activated within advocacy, but are dependent on a system that values peer and community voices [52, 53]. This insight is of particular importance for smaller organisations representing smaller or emerging populations without the resources that are built up over long periods in the sector; organisations that do not have funding power have other mechanisms that they could work through.

The plurality of perspectives on power incorporates elements from multiple frameworks. The idea of power as a form of control or influence of actors over other actors or the network is implicit in the discussions around funding and organisational size, where size and money impart greater agency on some organisations. Power as a collective property was explicit in the discussions of the relationships in the network and the strength of connections between actors; the alignment of purpose and cohesion between organisations conveys weight and legitimacy to actors such as government and to communities. The discussions around advocacy and using diverse evidence as the basis for policies and programs highlight that power is embedded in the systems in which the actors operate.

As with most areas of health promotion, the Australian response to HIV and HCV depends on collaborative cultures and alliances across organisations that go beyond specific partnership projects. While developed over the history of the response, the different and recognised power mechanisms, through which each part of the sector could have influence, were a valued characteristic of the response. The results of this study provide insights for maintaining health promotion collaborations where there are power asymmetries and in environments that are characterised by both collaboration and competition. In particular:

• −Long term relationships need to be positioned in public health as more than an outcome of many short‐term collaborations but viewed as a strength and asset of a health promotion response, and worthy of investing in and reinforcing in government strategy and policy. That ‘power with’ of trusted collaborative relationships can be an enabler for each organisation's ‘power to’.
• −A network that values multiple intersecting forms of power can enable different pathways for influence by those with less power, acting as a check and balance to other forms of power. For example, the strength of the voice and influence of community within public health is a function of not just the capacity of a community to advocate, but the extent to which the public health culture and practice values and enables that community's power to be influential.

Understanding the different forms of power within long term networks, and how these forms of power intersect and interact, may assist health promotion networks to strengthen cultures, values and policies that ensure co‐existing and potentially balancing power dynamics enhance, rather than limit, collaborative practice.

5. Limitations

Context is an important factor when considering power dynamics, and the respondents in this study were all drawn from the Victorian HIV and HCV sector. The network of relationships in this sector is mature, having developed over 40 years. While conflict between organisations exists, the history of the network has been one of partnership and collaboration, and there has been considerable time to develop the ways of working which are now embedded in the culture of the sector. Other networks and other sectors will face different challenges in working together, and this will be reflected in the perspectives of people in the organisations. This research would benefit from being replicated and expanded in different settings. In particular, a focus on the intersection of the different forms of power mentioned by respondents is necessary; our inductive and open‐ended approach did not allow us to ask respondents about the interactions and interdependencies of the forms of power mentioned by others in the study.

6. Conclusion

The Victorian HIV and HCV network provides a useful insight into the multiple forms of power within individual organisations and as a collective sector, and how these forms of power are valued and interacted. These co‐existing forms of power enable influence to be achieved through multiple avenues, helping balance aspects of the power asymmetries between individual organisations in the sector. This research indicates the need to consider power in multiple and potentially balancing dimensions when developing policies to strengthen health promotion collaborative practice.

Additionally, the research suggests a practical exercise for those engaged in collaborations. By asking about power the respondents were able to articulate their understanding of how the collaboration functioned, the goals that they were collectively working towards, and the value they saw in collaborating with others. Victoria's HIV and HCV sector has historically collaborated well; how would dysfunctional cross‐sectoral health promotion collaborations respond? Further exploration of how stakeholders understand and experience power dynamics may be beneficial to understanding how best to foster good collaborative practice.

Funding

Funding for this research was provided by the Australian Research Council Discovery grant DP210102314.

Ethics Statement

Ethics approval has been obtained from UNSW's Human Research Ethics Committee (approval HC210686) and Thorne Harbour Health's Research Endorsement Panel (approval CREP/THH:22‐001).

Conflicts of Interest

The authors declare no conflicts of interest.

Chamberlain D., Keast R., Brown G., et al., “Locating Power in a Cross‐Sectoral Health Promotion Collaboration Addressing HIV and Hepatitis C,” Health Promotion Journal of Australia 37, no. 4 (2026): e70247, 10.1002/hpja.70247.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.