ARCHIVED - Crossing Sectors - Experiences in Intersectoral Action, Public Policy and Health

 

3. Intersectoral Action for Health: A Broad Spectrum of Approaches

The concept of intersectoral action was introduced at the International Conference on Primary Health Care in Alma-Ata, Kazakhstan in 1978. The primary health care model explicitly stated the need for “a comprehensive health strategy that not only provided health services but also addressed the underlying social economic and political causes of poor health” (WHO 2005b, p. 11). In the 1980’s, conferences related to IA and the Ottawa Charter further underscored the need to work between sectors to realise health gains. WHO notes, “A formal commitment to IA became part of many countries’ official health policy frameworks in the 1980s. However, the track record of actual results from national implemen-t-ation of IA was feeble... . IA to address social and environmental health determinants generally proved, in practice, to be the weakest component of the strategies associated with Health for All” (WHO 2005b, p. 15). In the 1990s, with the growth of knowledge on determinants of health, efforts to work across sectors also expanded. In 1997, the WHO hosted a special conference on IA (noted in the introductory comments of this paper). In 2000, the Bangkok Charter for Health Promotion confirmed the need to work across sectoral boundaries. Specific policies to address health disparities were subsequently developed in a number of OECD countries. The United Kingdom and Swedish policies are often cited.

In 2006, the European Union introduced Health in All Policies, a broad-reaching directive with implications for intersectoral policy development, implementation and evaluation (Evans & Vega 2006, slide 6). A “Health in all Policies” conference was held by the European Union in September 2006, for which the Finnish Ministry of Social Affairs and Health produced a book entitled Health in all Policies – Prospects and Potentials. The book describes Sectoral experiences in health in all policies on, for example, heart health or health at the workplace. One part is also dedicated to opportunities and challenges of health governance, another on health impact assessment. The conclusions recognize that even if in many policies, the combined strategy of other policies with health will be a “mutual gain”, in some cases the values and objectives of the various policy intentions can be incompatible. In such cases, it is suggested that aims and objectives need to be negotiated and compromises sought (Ståhl, T. et al. 2006).

Key developments related to intersectoral action for health
  • 1970s: Alma Ata, Primary Health Care
  • 1980s: IA Conferences, Ottawa Charter for Health Promotion
  • 1990s: WHO Intersectoral Action for Health for the 21st Century (Halifax Conference)
  • 2000s: Bangkok Charter for Health Promotion, Health disparity policies in OECD countries; Health in All Policies – EU (2006)

(Evans & Vega 2006)

This paper examines recent efforts‚—i.e., those undertaken within the past decade—to identify variables and patterns in order to gain a better understanding of IA developments in different socio-political contexts. Specifically, it addresses the following questions:

  • What types of problems has intersectoral action been used to address?
  • What are some of the different intersectoral action approaches that have been used?
  • How have these different forms of collaboration been categorized?
  • How can intersectoral action be strengthened?

The following sections identify a range of public policy challenges, along with specific intersectoral approaches to addressing them.

Intersectoral action at different levels of decision-making

Intersectoral approaches for health have been employed at many different levels of governance or jurisdiction: for example, through internationally-promoted programmes initiated by the World Health Organisation or other United Nations agencies, regional and national policy frameworks, sub-national initiatives, and community-based and settings-based policy development and implementation.

At the global level, examples of intersectoral action for health include:

  • the 2002 World Summit on Sustainable Development, which brought together a wide range of actors, including health sector representatives;
  • the Healthy Environments for Children Alliance, which was established as an implementation platform to facilitate intersectoral work on issues related to children’s health and the environment (van Schirnding 2005);
  • the Health for All movement; and
  • the United Nations Environment Program (UNEP)’s Sustainable Cities Movement. (Huchzermayer, Burton & Harpham 2001).

At the global/regional level, the European Union has used the implementation of health impact assessment (HIA) as a tool to identify linkages between health and other sectoral policies. Discussion relates to the use of health impact assessment as well as legislative bases for undertaking HIAs on policies deemed to influence health. The WHO Regional Centre for Environmental Health Activities, which promotes environmental health through technical support in 23 member countries, is an example of how such collaboration has been institu-tionalized. This collaboration stemmed from the need for sustainable development and natural resource management issues to address the complexity of environmental and health considerations at play alongside development issues (Lock & McKee 2005, pp. 356-60).

At the national level, intersectoral approaches have been used to address complex, multifaceted issues by combining the efforts of the relevant government departments and agencies into a single coordinated strategy:

  • In the United Kingdom and Sweden, broad policy frameworks or whole-of-government approaches address inequalities or inequities through intersectoral action and related strategies.

  • In Canada and Australia, intersectoral action experiences depicted in the literature reviewed focus on specific populations, such as children, or on settings (low-income communities, schools and workplaces).

At the sub-national level, intersectoral action has been used to address a range of policy challenges related to health equity:

  • Quebec’s 2001 Public Health Act “acknowledges that various laws and regulations of other government agencies can affect population health and well-being. Thus, it empowers the Ministry of Health and Social Services to undertake intersectoral action to support public policy development favourable to health” (Bernier 2006, p. 26). Two strategies support its implementation: the creation of an intra-governmental health impact assessment process, and contributions to the development of research. The research dimension includes “financial support to design new tools for assessing effects of public policy on health. A knowledge transfer program includes reviews and briefs to inform government ministries about the possible health impacts of laws and regu-lations being developed” (Bernier 2006, p. 32).

At the community level, networks often bring together a wide range of actors, such as clinicians, researchers, sectoral policy makers (e.g., health, education, social services, and environment), as well as civil society and private sector actors. These networks provide a vehicle for discrete groups, such as health professionals, community health organisations or community-based services, to work together in addressing areas of mutual interest. Examples include:

  • Australia’s Here for Life Networking Project (Queensland), and the High Street Community Linkage (Sydney) and Connexions (Melbourne) projects.

  • The New Zealand Ministry of Health’s identi-fication of three types of action (New Zealand Ministry of Health 2001) in com-munity-based intersectoral action for health:

    • overarching area, or settings-based initiatives: Health Action Zones, Healthy Cities, and Healthy Schools;
    • issue-based initiatives: community-based programs related to alcohol, injury prevention, nutrition, health and housing; and
    • case-management services: strengthening families, collaborative case management, social workers in schools, family service centres, and comprehensive services for children experiencing emotional, mental, and behavioural disturbances, and/or for children with multiple difficulties and needs.

Working between levels

Horizontal collaboration occurs across sectors (or across sub-sectors within a single sector). Generally, this type of collaboration involves individuals or groups from the same level of decision-making or jurisdiction, working toward a defined set of goals.

Vertical collaboration is working across jurisdictional boundaries to address policy challenges that require decisions by more than one level of govern-ment. It can refer to global institutions working with regions and national governments, or national governments working with state, provincial or municipal governments to address complex policy challenges. Vertical collaboration “brings together partners with unique charac-teristics and requirements related to their public sector role...it must respect the jurisdictional mandates and responsi-bilities of partners at different levels of government, while building on common values, interests and purposes” [Canadian] Federal/Provincial/Territorial Advisory Committee [F/P/T] on AIDS 1999, p. 4). It is often complemented by horizontal engagement of other parties, such as non-government organisations and private donors in low- and middle-income nations.

Observations on working across organisational boundaries in HIV/AIDS note that intersectoral action is strongest, and outcomes are best, when the collaboration is both vertical and horizontal:

IA is most successful when it includes vertical as well as horizontal collaboration. Combining both dimensions maximizes the likelihood of reinforcing and synergizing effects ([Canadian] Federal/Provincial/Territorial Advisory Committee on AIDS 1999, p. 4).

Weaving these elements together yields a resilient and durable end product, and provides a shield against inaction, flagging interest, or disintegration. At the same time, because of the wide range of interests involved, additional effort and negotiation may be required to reach a shared understanding of goals, approaches, respective roles, and accountability for outcomes.

Problems addressed through IA: Framing public policy issues

Intersectoral action is a strategy used to deal with complex policy problems that cannot be solved by a single country, region, government, department, or sector. Intersectoral action has been brought to bear on specific determinants of health, diseases, populations (e.g. indigenous peoples, children), geographic communities, health behaviours, and risk factors.

The literature reviewed also indicates that intersectoral action has been used to bolster community development, crime prevention, disease prevention, economic development, sustainable development, education and employment, health promotion, health protection, primary care, public health, public security, and social cohesion.

Each of these policy “entry points” brings with it a particular conceptual base; related assumptions, vocabulary, and measurement approaches; a set of institutional actors; and, commonly used policy instruments. The way in which an issue is framed often determines which government agency or agencies and other organisations will lead efforts to address the policy challenge. The impact of issue- framing is discussed further in Section 5: Approaches to facilitate joint action.

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