ARCHIVED - Conclusion

In our case study we have explored the whole-of-government approach to health promotion unique to ActNowBC, an initiative intended as the health legacy of the 2010 Vancouver Olympic and Paralympic Winter Games. Because our information is based on interviews conducted between October 2007 and September 2008, our report presents a work in progress.

Intersectoral approaches, their processes and mechanisms, are shaped by the contexts from which they emerge. Accepting this, the lessons learnt from an initiative like ActNowBC, what works and what does not, may not be completely transferable. However, our research revealed several factors that explain the achievements of ActNowBC thus far – both those attributed to the initiative and those to which it has contributed.

Leadership that seizes the opportunities to act

While leadership is an obvious and generic success factor for intersectoral initiatives, it is often less clear exactly what aspect of leadership is most noteworthy. With ActNowBC, we found leadership among politicians and senior civil servants by virtue of their ability to seize the opportunities at hand. This is a relevant leadership trait in contexts with shifting and competing priorities and where decision-makers need to react quickly with available resources rather than wait for ideal circumstances. The Premier’s steady commitment towards the principles of an integrated health promotion initiative is one of the key success factors behind the launch of ActNowBC, and the main reason why ActNowBC has been able to evolve and mature since 2005. His continuous support guarantees that ActNowBC is to remain high on the agendas of all Ministers, Deputies and Assistant Deputy Ministers. Senior civil servants involved in ActNowBC also manifested leadership in a number of ways:

• Taking advantage of the unrelenting concerns about rising health care costs to effectively advance a business case for health promotion and disease prevention with potential benefits to more than the health sector.
• Given the significant financial investments for the Games directed at specific communities, framing the health legacy from ActNowBC as a province-wide gain giving it political traction.
• Securing a one-time $25.2 million grant to a coalition of NGOs – the BCHLA– by promoting the similarities and complementarity between the government’s platform for chronic disease prevention and the pillars of the BCHLA strategy.
• Taking advantage of the financial momentum for the Games to secure $15 million for an incentive fund designed to “pull in” other Ministries.

There was also the ability to “sail the ship while you build it”, i.e. taking action without all elements in place. For example, waiting to have completed a comprehensive accountability framework for such an initiative would have delayed action significantly. In other words, ActNowBC decision makers have strived to find the right balance between planning and action.

Diverse horizontal and vertical strategies and mechanisms

Another key message from this case study is that a combination of strategies and mechanisms can increase momentum, in this case for health promotion, can distribute the accountability for an initiative and can contribute to its sustainability. With ActNowBC the combination includes:

• High-level political commitment:

The Premier’s commitment was the impetus for establishing ActNowBC as a whole-of-government initiative and continues to secure it as such.

• Publicly stated ActNowBC goals and targets:

While controversial and politically risky, the ActNowBC goals and stretch targets have acted as a lever to promote intersectoral work and at the same time have distributed accountability across health and non-health sectors all while keeping the initiative high on the political agenda. The targets have also given public visibility to ActNowBC as a health promotion brand of the current provincial government.

• Breaking down the silos in government – the horizontal dimension:

Barriers such as the lack of knowledge about chronic diseases and their societal impact and turf protection by government ministries have been tackled through:

• Internal “pull” strategies and mechanisms:
  
  • The incentive fund and the ADM Interdepartmental committee drew in non-health sectors to a shared understanding of the intersectorality of risk factors and challenges associated with chronic disease prevention and created better communication and cooperation across ministries.
  • The logic models and the integration of ActNowBC into high-level service plans are accountability mechanisms to ensure that each ministry contributes to ActNowBC.
  • Civil servants with skills for intersectoral work facilitated communication across ministries in the early phases of ActNowBC, particularly during the development of the logic models.
• Engaging civil society organizations and different layers of government– the vertical dimension

 

 

The $25.2 million grant to the BCHLA, challenges notwithstanding, represents a significant infusion to a variety of community-based grass roots projects, complementing the actions involving different layers of government.

What is next for ActNowBC?

At the point at which our study concludes,the ActNowBC initiative faces sustainability and evaluation challenges. There was a provincial election in May 2009. It is too soon to tell whether ActNowBC has been long enough in a “stabilization” phase to survive the changes that may come if a new party is elected to lead the government. It is also too soon to evaluate ActNowBC against all the stretch targets.

Some of the mechanisms used to increase and secure intersectoral action, like the incentive fund and the grant to a coalition of NGOs, may not recur. It remains to be seen if the whole-of-government way of promoting health and the coordination and collaboration seeded by the grant to the BCHLA have taken root sufficiently to continue without subsidy.

The literature provides no gold standard or definitive guidance as to how to structure and implement intersectoral action to achieve health promotion goals. And ActNowBC has not yet matured to the point where lessons can be drawn with potential for uptake by other jurisdictions. Nevertheless, we feel a transcendent approach has emerged from the performance story we have documented thus far – that the BC government has demonstrated an ability to “sail the ship while you build it”, moving ahead even though not all the elements nor ideal conditions are in place, for example, the accountability framework is only now emerging. And other ActNowBC actors, within and outside of government, are continually navigating changes and risk, striving to find the right balance between planning and action. We feel that the attitudes of key players and the cross-government intersectoral strategies and mechanisms they have accepted so far are examples of “promising practices”.

As we write this report, ActNowBC targets three (tobacco use) and five (healthy choices in pregnancy) have been achieved. The added impetus of ActNowBC propelled existing initiatives relevant to these two targets to a stronger level of engagement. ActNowBC has also contributed to expanding and enhancing training and grant opportunities in a holistic healthy lifestyles strategy aiming to improve equity in health in Aboriginal communities. In addition, a number of health promoting policy changes are said to have been aided by ActNowBC, directly or by virtue of its momentum. Among them, stronger tobacco control legislation, restrictions in using industrially produced trans fat, new guidelines for healthy foods in vending machines in BC public buildings and school health guidelines also related to vending machines and to physical activity levels.

Challenges notwithstanding, many respondents applaud ActNowBC as a bold, broad reaching and innovative undertaking. For others, still needed is government application of stronger policy instruments with impacts on determinants for ActNowBC to secure a lasting health legacy for the people of BC.

The quote below illustrates the type of initial changes needed for the intersectoral action to take root.

… I give this government full points for setting targets and trying to get us all thinking about things like service plans [for intersectoral action]. It really is a discipline that wasn’t particularly well-embedded in government prior to this administration…” (Respondent- Government)