ARCHIVED - Crossing Sectors - Experiences in Intersectoral Action, Public Policy and Health
5. Approaches to Facilitate Joint Action
This review of experience in intersectoral approaches reveals a range of interrelated tools, mechanisms and strategies. This paper defines tools as catalysts that have facilitated IA; mechanisms as institutional structures and arrangements; and processes and strategies as a broader combination of planned actions or initiatives toward a specific goal(s).
Supports for intersectoral action
Information—ranging from anecdotal evidence of the impact of social determinants of health on health inequities, to more formal information and knowledge-based tools—has served as a catalyst to involve multiple parties in developing healthy public policies, both within and beyond the health sector. The documents reviewed focused primarily on impact assessment tools, which were presented as a means of capturing information that may focus on or include a health dimension. Examples include Health Impact Assessments, Environmental Impact Assessments, Integrated Impact Assessments, and Geographic Information Systems. Each is briefly described below.
Health impact assessment (HIA) has been described as “a combination of procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population and the distribution of those effects within the population” (WHO European Centre for Health Policy 1999). It can be applied prospectively, concurrently or retrospectively. Lock and McKee note that in situations where there has been a decision, for political reasons, to proceed with a policy that has negative health impacts, IA contributed to awareness and made the decision-making process clearer (2005). Observed benefits of HIA include strengthening policy-makers’ understanding of how health is affected by different policy areas, subsequent development of a shared policy agenda, and improvement in intersectoral relations (Lock & MacKee 2005). HIA has been used as a mechanism to involve multiple stakeholders from within and outside of government.
An equity-focused HIA “uses HIA methodology to determine the potential differential and distributional impacts of a policy, program or project on the health of the population, as well as specific group within that population, and assess whether the differential impacts are inequitable’’ (Harris-Roxas, Simpson & Harris 2004, p. 1). The Harris-Roxas, Simpson and Harris review analysed four models: the Merseyside Guidelines; the Bro Taf Health Inequalities Impact Assessment; the Equity Audit; and, the Equity Gauge. They note that there is a “lack of clearly and systematically consolidated guidance on how to assess both the health impacts and health equity impacts of a proposal” (2004, p. 43), and conclude,
Many of those behind the increased inter-national interest in HIA are also promoting a health equity agenda, and there is increasing interest in how the two may be combined. Despite suggestions that equity should be considered in every HIA there is little enabling guidance available. There is a need, particularly in contexts where an explicit commitment to reducing health inequalities does not exist, for clearly structured, practical guidance on how to incorporate equity in HIA (2004, p. ix).
Other forms of impact assessment include environmental impact assessments (EIA), which include a human health dimension, and integrated impact assessments (IIA). IIAs attempt to capture a range of complex factors and these factors’ relationship with the policy intervention under consideration. IIAs bring together knowledge and perspectives from a range of social and economic areas to assess the multiple impacts of proposals or policy decisions. The UK’s Health Development Agency notes that since IIA “deals specifically with education, housing, transport and other determinants, it can be useful to think of IIA as a health determinants impact appraisal tool” (NHS Health Development Agency 2004, p. 4).
Geographic information systems (GIS) are used increasingly by a wide range of sectors to map variables such as demographic infor-mation, employment, income, health and disease patterns. The visual nature of GIS maps assists in identifying the distribution and degree of concentration of multiple variables. GIS is recognized as a valuable tool to facilitate dialogue between sectors on shared areas of concern and to initiate collaboration, with resulting impacts on health, education, housing and other indicators of social or economic development.
Other examples of types of information that have facilitated intersectoral action include natural disaster profiles in both developed and developing nations; surveillance information on hazards to human health; evaluation results; and, shared platforms for electronic networks.
There appears to be agreement that the health sector requires a broad spectrum of information tools to translate information and knowledge into evidence that will permit linkages to be drawn between sectoral policies, and health. In reviewing rural services innovations related to Health Action Zones in the UK, Asthana and Halliday noted the need to distinguish between information for professionals [within and outside the health sector] and information for users (2004, pp. 462-463). Beyond specific users, other audiences include the public, media, decision-makers, and other non-government organisations. The information tools highlighted in these examples help to explain the relationship between a proposed or implemented policy and human health, health equity, and the equitable distribution of determinants of health.
The creation of new organisational entities or institutional arrangements to support inter-sectoral action has been documented at many decision-making levels. At the global level, the 2002 UN Summit on Sustainable Development is an example of an event that brought together institutional actors from the environmental, energy, health, and industrial sectors to address the complex, long-term policy challenges of sustainable development (von Schirnding 2005).
At the regional level, EuroHealthNet is a not- for-profit organisation with the goal of contributing to a healthier Europe through promoting greater health equity between and within European countries and facilitating networking and cooperation among relevant and accountable national, regional, and local agencies in European Union (EU) Member States, Accession and EEA countries (Welsh Assembly Government 2003). While its members are health and social services agencies of national governments, active partnerships with other sectors are critical to advancing its priorities.
At the national level, the UK’s Social Exclusion Unit promotes multi-agency approaches for Health Action Zones, Education Action Zones, and Young Offender teams. In Canada, there are a number of existing cross-sectoral, interjurisdictional policy-making fora, including the Federal Provincial Territorial (FPT) Ministers of Health and the Environment, and FPT Ministers Responsible for Sport, Recreation and Physical Activity. These fora are used to discuss and reach decisions on policy issues of interest to participating sectors. Brazil recently established the Comissao Nacional sobre Determinantes Sicuaks da Saude (National Commission on the Social Determinants of Health), which is mandated to create equal and fair health opportunities for all (WHO Commission on Social Determinants of Health 2006a).
|Focus: SRI LANKA|
A national framework for health
Sri Lanka has proven to be fertile territory for intersectoral action for health. In 1980, the Charter for Health Development was signed by the Prime Minister and the World Health Organisation. The Government of Sri Lanka committed to attaining acceptable levels of health for all its citizens by 2000, and embraced primary health care as the key approach. The National Health Development Network, driven by the National Health Council (NHC) (chaired by the Prime Minister), was established to ensure political commitment to intersectoral action for health.
The NHC sets government policies regarding health care and mobilization of non-health sectors; coordinates multisectoral action; and, encourages participation in health care. Ministers of Health; Agriculture Development and Research; Higher Education; Finance and Planning; Local Government, Housing and Construction; Home Affairs; Labour; and Rural Development serve on the Council.
The role of decentralization in IA
Decentralization provided a strong impetus for IA. District Health Councils were established in 1981 to promote multisectoral action and intersectoral coordination in 24 administrative districts in Sri Lanka. Four key interventions had an impact on equity during these years: investment in human development, through access to education, health services and food supplements; development of health infrastructure; access to essential medicines; and, continued provision of medical supplies and food during periods of armed conflict (Perera 2006, p. 40).
Provincial Health Councils were established by constitutional amendment in 1987, and health administration was totally devolved. The line Ministry is responsible for policy formulation, hospital management, specialized campaigns, technical training institutions, and bulk purchases of medical supplies. The latest effort to decentralize occurred in 1992, when Divisional Directorates of Health Services were created.
Key developments related to health and equity have included the first poverty elimination program (1989); social marketing for leprosy elimination (1990); the establishment of Divisional Directorates for Health (1992); a population and reproductive health policy (1998); an intersectoral implementation approach for policy for the aged. A National Commission on Macroeconomics and Health (2002) was struck to reinforce national-level commitments to sustainable investment in health, particularly for the poor.
A master plan for health and development
In 2002, a ten-year master plan for health development was initiated. Five strategic objectives were established: to ensure delivery of comprehensive health services to reduce disease burden and promotion; to empower communities toward more active participation in maintaining their health; to strengthen stewardship and management functions of the health system; to improve human resources for health development and management; and, to improve health financing, resource allocation and utilization.
Although the plan lacks a specific strategic objective on intersectoral action, it is expected that IA will be explored under the second and third objectives. Plans include enhancing the participation of civil society and non-governmental organisations in promoting behavioural and lifestyle changes. To strengthen health stewardship, enhanced coordination and partnerships with other sectors is envisioned. The Health Sector Development Project, established in 2004, aims to strengthen the health sector’s capacity to fulfil this stewardship role.
Improvements due to factors within and beyond the health sector
Sri Lanka’s significant improvements in health indicators have stemmed from performance within the health sector itself, as well as major socio-economic developments in education, agriculture and other sectors. Education is now universally accessible and heavily promoted, and there are strong links with the health sector. Government (both national and local), the community, and non-governmental organisations play consistently strong roles in promoting intersectoral action for health and equity.
Strong political leadership and positive intersectoral synergies between health and other sectors appear to be key features of IA action in Sri Lanka. Free education since 1945, leading to high levels of female literacy, have promoted attitudinal changes and created a knowledge base that has weathered periods of economic decline. Nutritional status of poor families, mortality rates, and a host of social services (including water and sanitation systems) have improved dramatically, in tandem with the health system.
There are multiple challenges associated with further improvements to health equity and intersectoral action. Conflict in the North East (the 20 Year War) led to a deterioration of health status, infrastructure and human resources in the region. As a nation, the epidemiological transition to non-communicable diseases has taken place, with associated challenges for the quality of health services. While Sri Lanka is currently a low HIV-prevalence country, many of the risk factors are present. Intersectoral responses are included in a draft HIV/AIDS policy.
(For further detail, refer to Perera 2006, Intersectoral action for health in Sri Lanka, Institute for Health Policy, Sri Lanka).
Documents reviewed for this paper highlight a breadth of new institutional mechanisms. Although evaluation results demonstrating the impact of these relatively new institutions were not available, two observations are of note:
- The organisational titles of these institutions are not necessarily specific to health. While the health sector is an active participant, it is not necessarily the lead.
- Few of the sources reviewed referred to existing intersectoral decision-making fora at either the political or bureaucratic level. While the new mechanisms appear to have been designed to fill gaps that were not addressed by existing decision-making fora, the interaction between the new and existing machinery needs to be taken into account. The literature reviewed did not examine or provide insights into these dynamics.
The lack of financial mechanisms to support intersectoral action has been identified as a common barrier to IA. However, examples drawn from source documents highlight financial tools and mechanisms that may hold promise:
- Financial allocations exclusively for intersectoral action, with clear criteria on what does or does not constitute IA, can be combined with regulations that provide legal instruments to enforce intersectoral action in certain situations (WHO 2004, p. 19).
- Intersectoral action as a condition of funding is used by international financing institutions to require sectors to work collaboratively in addressing difficult issues (WHO 2004, p. 19). This incentives-based approach provides parameters that support cross-boundary work. The Government of Canada uses this approach for its Population Health Fund, which provides grants and contributions to academic, com-munity, and voluntary sector organisations to advance policy and program objectives related to children, seniors and other population groups and issues. Alternatively, a penalty-based approach has been used in some countries, with government sanctions for lack of transparency and bias against intersectoral collaboration (WHO 2004, pp. 19-20).
- Cost-sharing or resource pooling involves financial contributions by a range of government and non-government organisations for a specific population or issue that aligns with the organisations’ mandates.
- In-kind resources have been used by sectors that are constrained by the limitations of funding agreements to contribute non-financial resources (e.g., people, information, expertise, physical space and technology) to support shared objectives. The accountability requirements associated with in-kind resources are often less stringent than those for investments of financial resources. In-kind arrangements between organisations can offer greater flexibility to adapt to the changing needs of intersectoral work in the different stages of policy development, implementation, and evaluation.
The documentation did not elaborate on the details of these fiscal tools and mechanisms in the context of health information or institutional arrangements. However, financial incentives and disincentives are considered to have a strong influence on the behaviours of organis-ations and individuals in intersectoral action.
Legislation and regulations
Legislation and regulations, combined with other tools and mechanisms, may have implications for intersectoral action. The World Health Organisation’s International Health Regulations influence the health policies of all nations, with implications beyond the health sector (e.g., on the travel, food, and tourism sectors). However, the regulations do not necessarily require intersectoral collaboration.
Legislation has been used to formalise the establishment of intersectoral institutional arrange-ments. This has occurred, for instance, in the European Union (EU), with the establishment of the EU Health Commission and regulations governing the application of HIA to policy proposals initiated within and outside the health sector (Lock & McKee 2005, p. 357). Lock and McKee note, however, that despite the legal basis for HIA in the EU, capacity concerns often limit effective implementation.
Accountability requirements for public and private sector organisations vary considerably. In many nations, there is a growing expectation that organisations will demonstrate value for money and attribute outcomes to policy inter-ventions. Accounting for joint initiatives that involve more than one government may lead to tension between compliance accounting (with established rules and principles) and results-based accounting. Fox and Lenihan note that “today, citizens care at least as much about the ‘what’ as the ‘how’...they care about the outcomes of results achieved” (2006, p. 3):
Most joint initiatives do not seem to involve the kind of shared decision-making sketched in the community development example. On the contrary, much of the real work still happens in silos ... most of the real collaboration happens in the early stages when the partners are still trying to decide what they want to do together. While it may not be possible to give a full accounting of how those decisions were made, we probably don’t need one ... if there is a loss of trans-parency, it is likely marginal and we are quite willing to live with it to get a partnerships that leads to measurably better results (Fox & Lenihan 2006, p. 7).
Challenges related to accountability are particularly evident in initiatives where there is both horizontal and vertical collaboration. In Canada, the Vancouver Agreement is an example of a socio-economic initiative that brings together three levels of government, multiple departments, and community and private sector organisations to revitalise Vancouver’s downtown east side. Within this complex web of organisations, mandates and efforts, joint evaluation frameworks have been negotiated to assess both process and outcomes.
Planning and priority-setting
The literature provides little information on the use of ongoing planning and priority-setting processes. The documentation tends to focus on innovative rather than existing mechanisms, perhaps assuming that health and health equity themes are accepted components of regular government-wide planning and priority-setting cycles. The materials reviewed pay little attention to the degree to which, and how, IA is institutionalised within regular planning and priority-setting mechanisms or machinery of government.
Most socio-political contexts require major policy directions and related funding allocations to be determined through established decision-making processes. Treasuries play a leading or significant role in government-wide budget planning and priority-setting. The nature of their role, relative to health and other government sectors, is explored further in Section 6: Roles and Responsibilities.
Intersectoral action approaches
In addition to a range of tools and mechanisms to support intersectoral action, this review of experiences also revealed a range of IA approaches to address health and equity challenges – including place-based, staged and targeted approaches, as well as broad policy frameworks.
Place-based or settings approaches
Healthy Communities/Healthy Cities is a World Health Organisation initiative that focuses on implementation at the local level. This broad concept uses “settings” as structures that provide methods of reaching defined populations. Since its inception, Healthy Cities has included cities, municipalities, villages, islands, communities, schools, and places of work (Werna et al. 1998, p. 74 in Huchzemeyer et al. 2001, p. 12).
The UK’s Health Action Zones (HAZ) initiative built upon the Healthy Cities Movement model, and provides an example of locally- managed approaches to improving health equity. Under the Labour government, national redistributive efforts were complemented by local action in disadvantaged areas that had been identified as communities in critical need. Zones were considered a key means of “tackl[ing] root causes of ill health – poverty, unemployment, homelessness and family breakdown. They followed government initiatives in other social areas – education action zones, employment action zones and young offender teams ... [and] Ministers hope [they] will lead to closer cooperation at the local level to tackle social deprivation (Dean 1998, p. 1111). Initiatives involving income, employment, education, early childhood development and [community] regeneration were combined, and partnerships among government, the private sector, and communities were established (WHO Commission on Social Determinants of Health 2006c).
Dahlgren and Whitehead comment that the settings approach “has been used to tackle health hazards at work and focuses on major determinants of health in a certain workplace, rather than on a single risk factor.” However, they caution that “the equity in health dimension of these programmes – Healthy Workplaces, Healthy Schools and Healthy Hospitals – has sometimes been weak”. They also note “the need within this approach to identify the determinants of social inequities in health ... special efforts should be made to initiate setting based initiatives in disadvantaged communities” (2006, p. 101).
The scale of place-based approaches may vary significantly, and a range of sectors and jurisdictions may be involved. However, the setting provides a shared platform for action. Place-based IA has the advantage of tangibility and visibility: it is conducive to site visits for decision-makers, the media, and stakeholders to examine the public policy problem and related interventions.
Other global, national and local examples use staged approaches through joint planning and policy workups to develop options, recommendations and action plans. At the global level, in deliberations related to Water, Sanitation, and Health Protection of the Human Environment, there are participants from the health, agriculture, environmental, natural resources and economic sectors, including multilateral government and non-government organisations. Through the Development Policy Forum, senior-level officials hold informal dialogues on cross-cutting public policy issues related to water, sanitation and health protection. Established in 2001, the initiative brought together sectors with shared interests and impacts, and reported to the World Water Forum in Mexico in 2006.
Bos (2006) noted two essential elements in this approach:
- undertaking a joint review of all sectoral policies to foster harmonisation and incorporate health issues into sectoral policy development, where useful; and
- establishing institutional arrangements within a strengthened policy framework to identify the potential of existing arrangements; establishing specific institutional arrangements on health issues in development; identifying partners and the content of collaboration; and, putting the mechanisms in place with resources. Experience has shown that without adequate resources, intersectoral actions seldom have lasting impact. Finally, Bos recommends developing clear Memoranda of Understanding to formalise more permanent arrangements, provide clearer links to intersectoral bodies, establish clear mandates, and provide adequate resources.
Three process steps were noted: situation analysis of institutional arrangements; identification of obstacles to intersectoral collaboration; and, the development of ideas to bridge intersectoral gaps (WHO 2004, p. 18).
In 2005, the Norwegian Directorate for Health and Social Affairs initiated a staged approach to reduce social inequalities in health.
Phase One involved increasing knowledge on social inequalities in health by strengthening expertise, research, and documentation. Impact assessment was used as a tool to measure the impact of policies, programs and projects on social inequalities in health. The organisation ensured that the Directorate’s own policies took social inequalities into account, and prepared a professional basis for a national strategy involving all sectors.
In Spring 2007, the Norwegian government submitted a report to the Stortling [the National Budget] presenting its strategy to reduce social inequalities in health.
The Norwegian government has given priority to strengthening the responsibilities and role of the public sector within key welfare areas such as health, care services and education. The strategy to reduce social inequalities in health establishes guidelines for the government and central administration’s focus on and promotion of social equalisation of the most important determinants of health over 10 years (2007-2017).
(For further detail, refer to Directorate for Health and Social Affairs 2005 and The Ministry of Health and Care Services 2006).
These staged approaches appear to be employed where the need for sectors to act in concert to improve health and health equity is recognized, and where there is a strong push for evidence to support choices about where and when to act collaboratively. Risks associated with this approach include potential loss of support between developing the evidence base, options development, and making decisions. Advantages associated with this approach include developing stronger evidence across a broad spectrum of determinants of health and equity, reaching better-informed decisions, and making more effective, efficient use of resources.
Given resource constraints and the desire for timely and visible results, decision-makers may choose to focus or target efforts on a specific population or issue. The literature reviewed includes two main types of targeted approaches: population or group-based; and, disease or risk factor approaches.
In Chile, the Ministry of Planning and Coordination established the Solidarity and Social Investment Fund, Programa Puente (Bridge Program), which targets families in extreme poverty. The program involves all policy-making sectors that influence health, and uses selective interventions to tackle inequities. Counsellors work with families to link and facilitate access to services. Financial incentives are in place for employers who hire unemployed heads of households covered by the program. The number of families served by the program has increased substantially. Results on the health, social and economic impacts of the program were not available (WHO Commission on Social Determinants of Health 2006b).
The poor health status of indigenous peoples in many countries is well-recognised. New Zealand, Australia and Canada are among the nations that have used targeted intersectoral approaches to address the complex social and economic challenges of indigenous peoples. Aboriginal community, regional, national, and international organisations are exploring ways to reduce inequities. Government partners include education, health, social services, economic development, natural resources, environment, and population-specific departments, e.g., Indian and Northern Affairs Canada.
Disease or risk factor-specific
Strategies focusing on a specific disease, risk factor, or groups of risk factors have been used by many countries. Dahlgren and Whitehead note that disease-specific approaches focus on the downstream factors in the causal chain, but they acknowledge that “sometimes, a coordinated systematic approach that focuses on a specific disease is effective in mobilizing public action” (2006, p. 101). Common risks associated with this approach include duplication of efforts and a narrow focus on downstream effects.
These targeted approaches may be useful in situations where there is a strong public and stakeholder perception of the need to address a specific population group, disease or risk factor, e.g., Low-income families, Severe Acute Respiratory Syndrome (SARS), HIV/AIDS, and tobacco use.
Broad policy frameworks
Examples of broad policy frameworks with health implications are the UN’s Agenda 21: A Plan to Achieve Sustainable Development and Europe’s National Environment and Health Action Plan. The United Kingdom (UK) and Swedish cases are the more frequently-cited examples of broad policy frameworks with a central health equity focus. Highlights of these approaches are included in text boxes on this and the pages that follow.
New Zealand’s approach to addressing health inequalities encompasses four levels of intervention (Crombie et al. pp. 22-23). Structural elements include education, social security, and labour market policies favouring those at the highest risk of unemployment. Health professionals advocate for other sectors to introduce policies that will improve health and reduce inequalities in health. Actions to address intermediary pathways include policies to improve living and working conditions and community and school-based programs, complemented by health and disability services to ensure equitable access and elimination of barriers. These actions are designed to minimise the impact of disability and illness on socio- economic position.
|Focus: UNITED KINGDOM|
In 1980, The Black Report, which identified health inequalities in the UK population, ignited debate on the extent of the inequalities and contributing determinants. The Wanless Report, a cross-cutting review of national policy and evaluation reports on inequalities that explored child poverty and transportation, also prompted action. However, despite acknowledgment of, and ongoing discussion about the situation, it was not until the Labour Party came to power in 1997 that the UK produced a dedicated national policy on addressing health inequities. Until 2005, it remained the only country to have taken such an approach.
Joined-up government adopts IA as a key strategy
The policy places the responsibility for dealing with health on government as a whole. Within that framework, IA is recognised as a key strategy for addressing health inequity. Further, the concept of “joined up government”, defined as “the bringing together of a number of public, private and voluntary sector bodies to work across organisational boundaries towards a common goal” (National Audit Office 2001), emerged as a mechanism to facilitate the implementation of IA. The push toward IA was viewed as part of the process of modernizing government. The Cabinet Office and Treasury were made responsible for promotion and monitoring. Related national policies on children and neighbourhood renewal were introduced during the same time frame.
Numerous challenges impeded progress
Politics represented the greatest barrier to achieving IA in the UK. Until a Labour government was in place, IA was not a priority. The establishment of Health Action Zones is one of the government’s best-documented examples of IA. Twenty-six Health Action Zones (HAZ) were established to organise area-based action around the social determinants of health. They were linked to the Social Exclusion Unit responsible for promoting multi-agency approaches for Health Action Zones, Education Action Zones and Young Offender teams. Intended to foster inter-agency and intersectoral collaboration, as well as harness community-based resources and experience, these Health Action Zones were scheduled to operate for at least seven years. After a high profile start accompanied by considerable enthusiasm for the concept, most of the Zones were shut down after three years, due to shifting government priorities.
Bauld (2005) observes that the experience of each Zone was highly context-specific, and there is evidence of long-lasting benefit in terms of learning about intersectoral ways of working. In short, Zones made a “good start in difficult circumstances”, which included unrealistic objectives; inadequate funding; constantly shifting objectives and partnership arrangements; performance management systems that provided few rewards for IA; shortfalls in organisational capacity; and, tension between effecting local change while identifying structural causes of inequity nationally.
Obstacles and positive outcomes
Most Health Action Zones were shut down before their impact could be properly evaluated. However, some evaluators, while acknowledging the ambiguous nature of the data gathered from the Zones, have argued that there is evidence of long-lasting benefits in terms of learning about intersectoral work. These benefits include: introducing an improved service delivery model for previously overlooked population groups; and, creating a context that supported new and more constructive ways of working together (Bauld et al., 2005, p. 438). Additionally, the Zones gave health inequalities a greater political profile, at least locally.
While cross-departmental working groups have emerged on thematic issues, and Ministers for different departments jointly sign strategy documents, there is evidence that departments may continue to work in individual “silos”, and that they lack a sense of collective ownership of intersectoral policies (Exworthy, Berney & Powell 2002). The UK government remains dedicated to the concepts of joined-up government and intersectoral action, seeking to build on past experience to enhance intersectoral and interagency working both nationally and locally.
Lessons from experience
Documented lessons learned on IA under the Labour government in the UK (National Audit Office 2001), (Exworthy, Berney & Powell 2002), and (Bauld 2002) include the need to:
(For further information, refer to the National Audit Office 2001, Exworthy, Berney and Powell 2002 and Bauld 2005).
Dahlgren and Whitehead discuss “integrated determinants of health strategies’’, indicating that one of the most effective approaches is to “integrate health equity objectives into existing social and economic policies and programmes for economic growth, taxes, employment, education, housing, social protection, transport and health services” (2006, p. 100). The authors note “a high priority must be placed on the development and use of health equity impact analyses ... health equity impact assessment – as with environmental health impact analyses – be considered a normal part of any assessment of public and commercial policies and programmes that are likely to have positive or negative effects on health. It may be necessary to make such health impact analyses compulsory by law or regulation.”
Intersectoral action for health linked to social determinants by a proactive government
Intersectoral approaches were used by national and local governments in Sweden well before the release of the Black Report. Sweden’s current national public health strategy has emerged out of a social welfare model and recognition of health inequities identified in the 1980s. Significant research into the nature of these inequities and related intervention approaches provided evidence to support broad-based public health objectives. Ultimately, this focus was linked to a social determinants framework, with an overarching intersectoral action component.
Factors that contributed to the development of national public health goals included: a history of social democratic government; a strong relationship with the labour movement; a highly developed welfare system; a call from municipalities for national public health goals; involvement of politicians from across the political spectrum; strong civic literacy; a highly democratic process; political commitment to equity; a high level oversight body; intersectoral goal-setting; a strong evidence base; and, a preference for collective, systemic approaches (Östlin 2003).
A comprehensive national strategy
The National Public Health Commission asserts that “we consider that responsibility for individual health is divided between the individual and society, whilst the responsibility for injustice in the distribution of health between groups is first and foremost a matter for society” (National Committee for Public Health 2001).
Sweden’s Health on Equal Terms public health goals and strategy provided a philosophical and practical framework for cooperation among multiple sectors and actors in relation to major health determinants. The goals, based on strong scientific evidence and developed in a democratic process, identified roles and established targets related to determinants of health.
The national policy governs intersectoral actions at the county council and municipal levels, which makes public health a shared responsibility among several central agencies, Sweden’s 21 county councils and its 290 municipalities. In addition, the policy embraces non-government organisations, trade unions and universities. The breadth of this approach offers a unique model for governing intersectoral action for health and equity.
Overcoming barriers through solid research, consultation, and inclusion
Initially, Sweden lacked a long-term comprehensive strategy to overcome health inequities. The process of goal development included three key steps: framework development and discussion; ethical values, scientific facts and priority setting; and, finalising the strategy. Experts were commissioned to gather scientific data pinpointing needs. Multidisciplinary research into health determinants was undertaken and analysed. Active participation of all seven political parties was a critical element in shaping policy directions.
The inclusive nature of the process—i.e., ensuring that opposition parties, the public, and other stakeholders took “ownership”—is of particular note. Public consultations heightened citizen awareness and involvement. Key documents were made available to the public in a variety of formats, including Braille. The public health goals process initiated in 1998 led to the adoption of The Public Health Objectives Act (2003), Sweden’s first formal public health policy and one of the world’s first formalized health strategies employing a health determinants approach. Through this Act, Parliament endorsed the broad goal of “provid[ing] societal conditions for good health on equal terms for the entire population”. Eleven public health goals under three categories (social structures and living conditions; settings and environments; and, lifestyles and health behaviours) support this overarching goal.
Specific, measurable targets were established for each of the 11 goals. Rather than imposing new goals on other sectors, there was a decision to integrate the goals relating to employment and social supports from other sectors into public health goals (Östlin 2003).
Health leads the way
The health sector drove the initial stages, and facilitated the process throughout, by calling for research into health inequities and providing the expertise required to generate hard evidence to enable the political sphere to lead the process. Other sectors also participated: multisectoral and multidisciplinary research into the issues highlighted the inequities present in the system. The involvement of government, non-government organisations, experts and the public throughout the process was instrumental to the approval and early implementation of the public health goals and strategy. A Steering Committee chaired by the Minister of Public Health, with Ministers from other sectors participating, oversees the ongoing implementation of public health goals that fall outside the health sector.
Monitoring and evaluation techniques under development
Though it is too early to assess the impact of the new policy, the Swedish National Institute of Public Health has been tasked with monitoring and evaluation on behalf of the Steering Committee. Developing the methodology to monitor and evaluate the intersectoral components of Sweden’s public health policy is challenging.
(For further detail refer to: Östlin, P. & Diderichsen, F. 2001, ‘Equity-oriented national strategy for public health in Sweden: A case study’, Policy Learning Curve Series Number 1, WHO European Centre for Health Policy, Brussels. [On-line] Available at: http://www.who.dk/Document/E69911.pdf)
Evidence of the effectiveness of these broader policy frameworks was not provided in the materials reviewed. While frameworks offer the advantage of integrating knowledge and efforts toward shared objectives, they may also present challenges in developing, implementing and evaluating policy, due to the large numbers of participants and the differing perspectives involved: for instance, sustaining interest among the wide range of stakeholders; measuring impact; and, providing timely evidence for decisions in a dynamic environment. Risks may include a perceived loss of focus on the health sector’s work to ensure equitable policies. Clearly, a strong analytical capacity within participating sectors is required to identify areas for assessment and to advise on options in a timely manner.
In many cases, a combination of these approaches is employed. At the national level, governments may select a targeted approach for a specific population, combined with a staged approach for a particular emerging issue. Evaluation results of combined approaches were provided, where available, but generally, there is little evidence of the effectiveness of intersectoral versus intrasectoral action for equity goals. Attribution challenges are significant. In many cases, decades may pass between implementation and the achievement of outcomes.
Experience demonstrates that working across sectors places heavy demands on resources. The resource limitations of an individual sector may mean that it cannot afford to work on all issues, at all times, with all of the relevant stakeholders. Choices must be made on which issues to address, with which sectors, at which time. While health gains are not necessarily an explicit priority for other sectors, health is a critical indicator of social and economic development. Equity may serve as the common ground for stakeholders in moving toward more equitable distribution of health and determinants of disparities in health.
Within the context of this paper, it is difficult to assess the appropriateness of each of these approaches for a specific decision-making context. However, the range of examples cited provides some insight into the scope of IA approaches. Clearly, context and culture matter in selecting an approach, and will also influence the effectiveness of the approach that is chosen.
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