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

 

4. Intersectoral Action: Navigating Barriers and Enablers

Drivers of intersectoral action

The need to act is a core driver for IA efforts. Additional drivers for intersectoral action have included:

  • lobbying and political pressure from the public, opposition parties, non-government organisations, the media, or coalitions of interested groups to address a significant policy challenge;
  • favourable economic conditions supporting intersectoral action to address complex policy challenges. Since IA often costs more in the short-term than simpler, “quick-fix” responses, strong economies may offer the resources for sustained investment in intersectoral work. In periods of fiscal constraint, innovative approaches to cross-sectoral actions may be undertaken as a means of addressing overlapping and intersecting organisational mandates;
  • the existence of a “feedback” loop between citizens and government, to drive, define and respond to the issues. Timely information-sharing between citizens and government is required;
  • strong central agencies that oversee and guide approaches to ensure that organisational mandates, authorities and reporting are respected. While central agencies do not necessarily lead these approaches, they often play a strong support role in ensuring adequate resources for initiatives; guiding policies through formal decision-making avenues; and, designing and monitoring compliance with accountability frameworks; and
  • negative data from reports of commissions and/or task forces, studies, statistics, poll results. Bad news sometimes attracts more public and political attention than success stories. Comparing nations’ health status and conditions for health can spark interest in intersectoral efforts to address shared problems and promote equitable conditions for health and social development.

The documented experiences clearly demonstrate that context and culture are critical to the success of intersectoral initiatives. Conditions or approaches that obtain results in one sector, or one environment, may not necessarily prevail in another. The literature suggests that while there is no universally “correct” way to proceed with IA efforts, adhering to certain principles promotes IA success.

Presentation materials related to health promotion in schools (Rowling & Jeffreys 2005) illustrate this point. Challenges in achieving collaboration between the health and education sectors included: “vertical funding; professional diversity of paradigms and views; competing priorities and decision-making processes; and complex processes of engagement.” While health research relied on the assumption that health promotion strategies have the potential to work equally well in all schools, educational research captured the critical point that schools have vastly different cultures [e.g. compare rural with inner-city schools]—cultures which depend on a variety of shifting factors. Effective collaboration between the sectors could only be achieved if the partners are able to see “mutually beneficial outcomes, feasible implementation strategies and compatible monitoring and evaluation methods.”

In conflict-driven and politically fragile states, intersectoral actions have proved vital in restoring security and promoting health equity. The breakdown of government has, in some circumstances, yielded an opportunity to establish IA as an accepted way of working— an outcome that is not always possible in more established environments (WHO: Health Systems Knowledge Network 2006).

The literature demonstrates that good intentions do not always translate into successful intersectoral initiatives. Australia’s National Youth Suicide Prevention Strategy fell short of stated objectives due to a host of unintended factors: lack of consultation with states and territories; insufficient networking; inexperienced project staff; and, inadequate government planning processes. Australia’s experiences with the Strategy teach a valuable lesson on the importance of advance planning to avoid pitfalls and mitigate risks.

Conditions for effective intersectoral action
  • The parties have identified a need to work together in order to achieve their goals. This requires clarity on individual organisational goals, as well as joint goals.
  • In the broader operating environment, there are opportunities that promote intersectoral collaboration, e.g., the community understands and is supportive.
  • Organisations have the capacity—the required resources, skills, and knowledge—to take action.
  • The parties have developed a relationship on which to base cooperative, planned action. The relationship is clearly defined and is based on trust and respect.
  • The planned action is well-conceived and can be implemented and evaluated. The action is clear and there is agreement to undertake it. Roles and responsibilities are clear.
  • There are plans to monitor and sustain outcomes.

(Adapted from: Harris et al. 1995)

Conditions for success

Many sources provide advice on conditions for IA success at local, national, and regional levels, and across jurisdictions (F/P/T Advisory Committee on HIV/AIDS 1999; WHO 1997; Swedish International Development Co-operation Agency, 1999, Rychetnik & Wise 2004, Canadian Public Health Association 1997). “Working together: intersectoral action for health” (Harris et al. 1995) provides a comprehensive list of these enabling factors, or conditions of success.

Other readings and checklists offer additional variations and considerations (Rachlis 1999; FPT 1999; Bauld 2005 and Goumans 1997). Many lists of “enablers” include some of the elements listed below:

  1. Create a philosophical framework and approach to health that is conducive to IA. For example, favouring health determinants over a disease-driven approach automatically builds connections with other sectors and allows them to see a role for themselves in addressing the problem.

  2. Emphasize shared values, interests, and objectives among partners and potential partners. Many writers have emphasized the importance of seeking trust and shared values: individuals engaged in IA must be like-minded. Personal values, for individuals, are more significant indicators than association with organisational values. Societal values that align with the objectives of IA can also be influential.

  3. Ensure political support; build on positive factors in the policy environment. Often, politicians lead or champion progressive IA initiatives, both within and beyond the health sector. Strong connections with political leaders, administrators and the media are key to securing their support.

    A clear mandate and a supportive policy environment are equally desirable in fostering a sense of solidarity, facilitating collective action, acknowledging the requirement for long-term investment in IA, and boosting a favourable economic climate. Alternatively, the intersectoral initiatives themselves may identify the creation of a more supportive policy environment for the future as a specific goal. A proactive stance is encouraged. This means, for example, assisting senior decision-makers and policy-makers in all sectors to understand the benefits of IA, and encouraging them to foster intersectoral action in research, policy and practice.

  4. Engage key partners at the very beginning: be inclusive. Strong, dedicated partners are critical to the success of intersectoral action. Involving the right people and institutions, and reaching beyond government to involve civil society and the voluntary sector, are vital steps.

  5. Ensure appropriate horizontal linking across sectors, as well as vertical linking of levels within sectors. When links are drawn across sectors and between levels of government, the resulting “fabric” is stronger. However, it is essential to recognize the potential for failure due to inadequate communication or consultation, lack of policy coherence, lack of clarity on respective roles, and/or lack of sensitivity to power imbalances.

  6. Invest in the alliance-building process by working toward consensus at the planning stage. Ensuring that the action is well-planned, or that there is a good relationship between the parties, does not guarantee success. Efforts can be strengthened by engaging all players at the outset, confronting differences, and inviting collaboration in the planning process.

  7. Focus on concrete objectives and visible results. The act of establishing health goals, on its own, has done little to promote intersectoral action. Some Canadian provinces have chosen to set overarching, whole-of-government goals, but it is too early to determine whether this approach has been effective. It is also difficult to monitor achievement toward such goals.

    While short-term gains may be highly motivating, they can also be counter- productive, as in the case of the United Kingdom’s Health Action Zones.

  8. Ensure leadership, accountability and rewards are shared among partners. Increasingly, people and organisations in the health sector play different roles in IA. Partners must learn to be effective, whether they are acting as catalysts, leaders, partners or supporters. All partners in intersectoral work must be able to perceive that the process is mutually beneficial and that responsibilities and rewards are distributed appropriately.

  9. Build stable teams of people who work well together, with appropriate support systems. Goumans (1997) draws a distinction between “core group” and “peripheral group” participants. Core group participants are committed ideologically to the concept of IA, while peripheral group participants are involved because the activity relates to their particular interests. This observation highlights the important role that individual participants play in effective intersectoral action. Adequate capacity and resources, shared goals, mutual respect, and trust make it easier for individuals to make long-term commitments to working across sectors.

  10. Develop practical models, tools and mechanisms to support the implementation of intersectoral action. A lack of appro-priate support mechanisms can serve as a barrier to intersectoral action. Collaborative planning models, evaluation frameworks that assess multiple indicators, shared accountability models and innovative governance structures are examples of tangible support.

  11. Ensure public participation; educate the public and raise awareness about health determinants and intersectoral action. The existence of a clear channel of communication between citizens and government is needed – to give and receive feedback; to properly evaluate the success of intersectoral action; and to take corrective measures, as necessary. Whole-of-government approaches create additional imperatives for successful intersectoral action. Once there has been a decision that it is necessary to work together, care must be taken in determining how to do so. Suggested actions to create conditions for success include (National Audit Office 2001, Exworthy, Berney & Powell 2002, Bauld 2005): reinforcing the policy direction with a statutory duty to collaborate, where appropriate; ensuring that partner organisations align their vision and policy objectives, and that central agencies (while providing appropriate guidance) avoid undue interference in partnerships; providing incentives for joint working (e.g., financial incentives, flexible decision-making, or appropriate performance assessment). Reducing the variety of funding streams, using pooled budgets, and reducing administrative and reporting burdens are also effective incentives; setting realistic time frames to achieve results; and ensuring that there are clear lines of redress for citizens, as well as a clear accountability framework.
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