ARCHIVED - Section 2 Definitions and Scoping Review of the Literature
The term intersectoral action has a broad meaning, and as a result, has different interpretations. For this study, we adopted the definition contained in a 2008 Senate Report on Population Health Policy in Canada. This definition distinguishes between the horizontal and vertical dimensions of intersectoral action:
“The horizontal dimension links different sectors such as education, health, the environment, etc. Within a single government, this can be referred to as an interdepartmental or whole-of-government approach. The vertical dimension links sectors at different levels; for example, the federal, provincial/territorial, regional, and local or municipal governments are linked both together and with groups, institutions, and organizations in the community.” (Senate Report, 2008) 
From that perspective, the concept of intersectoral action overarches the concept of whole-of-government. In our case study, we adopted the following definition of whole-of-government:
“…whole-of-government denotes public service agencies working across portfolio boundaries to achieve a shared goal and an integrated government response to particular issues. Approaches can be formal and informal. They can focus on policy development, program management and service delivery.” 
Other terms have been used to capture the ideas contained in the above definition, for example, joined-up government and horizontal management.
Since the Alma-Ata Declaration of 1978 and the concept of Health for All, momentum has grown internationally for public health policies to work upstream and outside the health sector.  The 2005 Bangkok Charter for Health Promotion in a Globalized World recommended that “the promotion of health [be made] a core responsibility for all of government.”  The underlying principle, now firmly grounded in empirical evidence, is that economic and social development are strongly interconnected with health. WHO strategies for tackling chronic diseases have always advocated multifaceted approaches involving multiple sectors. , 
At the international level, a number of countries have begun experimenting with different forms of intersectoral action and whole-of-government approaches1 to address complex health and social issues. In the United Kingdom, for example, policy analysts credit the Blair government for introducing the concept of “joined-up government” in 1997.  Key advisors and ministers within the Labour Party became convinced that many of the most difficult social and health issues cut across departmental remits and required a joined-up solution.  However, intersectoral action and whole-of-government approaches take different forms, depending on how the issue is framed and what the desired outcome is. Increased coordination and efficiency are common and cross-cutting goals. Specific outcome goals are more varied, for example, improving health per se, acting on a specific risk factor or determinant of health, or targeting a specific subgroup of the population.
Nevertheless, the previous decade of experience in intersectoral action in general and in the use of joined-up approaches more specifically has not convinced all analysts that real and sustainable progress has been made. Empirical evidence is still limited on how to successfully implement and sustain such intersectoral and whole-of-government approaches.
The main purpose of this section is to identify the key themes and conditions for successfully adopting effective intersectoral action. We place special emphasis on whole-of-government approaches, which is the core (and initial) orientation of ActNowBC. This high-level mapping of intersectoral action themes and success factors provides readers with a lens through which to interpret the case study findings.
We report the results of our scoping exercise by focusing on three key interrelated themes: coordination, governance, and accountability.
Coordination 2 is the “umbrella” theme associated with whole-of-government approaches. Better coordination is the main desired consequence of whole-of-government initiatives and is seen as an essential condition for achieving a common goal or set of goals. All whole-of-government initiatives strive for more inter-ministerial coordination. However, several studies on whole-of-government approaches conclude that a gap between talk and action often occurs because of significant barriers to coordination.  Discussions about barriers to coordination inevitably lead to the theme of governance. Figure 1 presents three categories of coordination mechanisms directly related to the theme of governance that we will use in the next section.
Figure 1 – Text equivalent
The first category is labelled “Behind the Handshake”. It refers to the fact that fundamental changes in organizational cultures are necessary to facilitate whole-of-government approaches in planning and executing programs and policies. Without this backdrop, the use of coordination mechanisms is unlikely to lead to success.
The second category, called the “Visible Hand”, emphasizes the fact that strong leadership is a condition for successful intersectoral action.
The third category is called ‘The Invisible Hand”. It emphasizes the fact that whole-of-government initiatives need to be supported with an appropriate level of resources and a sound organizational structure. Whole-of-government initiatives may, for example, benefit from a management culture that relies less on command and control, and more on financial incentives, continual monitoring, and ongoing consultation and engagement.
Adapted from a manuscript of the Mansholt Graduate School of Social Sciences. 
The concept of governance refers to:
“…the procedures associated with the decision making, performance and control of organizations, with providing structures to give overall direction to the organization and to satisfy expectations of accountability to those outside of it.” (Hodges et al., 1996: 7) 
Governance can also refer to a set of structures designed to support coordination or to define how coordination should occur. The categories of coordination mechanisms presented in Figure 1 will be used to outline some of the whole-of-government conditions for success.
-(Behind) The Handshake: Developing a Backdrop to Action
Fundamental changes in organizational cultures are necessary to facilitate whole-of-government approaches in planning and executing programs and policies. Organizational culture can be defined as a “fairly stable set of taken-for-granted assumptions, shared beliefs, meanings, and values that form a kind of backdrop to action.” (Smircich, 1985: 58)  A report published by the Canadian Centre for Management Development (2001) focusing on horizontal management highlighted that coordination is easier when organizational members share the same values, norms, fact base, goals, and understanding of the key issues.  Another Canadian report on horizontal management concluded that shared mental models and vocabularies help give an initiative a working culture, a prerequisite to developing trust.  Without this backdrop, the use of coordination mechanisms is unlikely to lead to success. Informal structures may be needed in order to stimulate a shift in culture and the development of shared frameworks and mindsets. For example, a report about Policy Action Teams in the United Kingdom in the 1990s, in which the teams comprised of government officials from a range of departments, outside experts, and residents, concluded that these teams worked best with overt team-building activities (such as site visits and away days) and meetings held in an informal environment and style.
Whole-of-government initiatives should also have a clear purpose to ensure that partners align their vision and policy objectives. Unrealistic objectives can be a barrier to cross-ministerial work., ,  Organizational and individual expectations have to be taken into account during the design and implementation phase of a whole-of-government initiative.
-The Visible Hand: Leadership and Authority
Strong leadership is a condition for successful intersectoral action. For example, Backvis and Juillet, in a key report on horizontal management among federal departments and agencies in Canada, concluded that the most important determinant of success was the presence of specific individuals acting as catalysts and champions at finding innovative solutions and resources. Conversely, the perception of a lack of coherent and consistent leadership from central agencies (e.g. Privy Council Office, Treasury Board Secretariat) was a cause of frustration among respondents.
Defining the concept of “leadership” remains difficult since different forms of leadership present at different levels may be needed for successful coordination. In general terms, leadership may be viewed as creating a way for people to contribute to making something extraordinary happen.  In the field of public health, “leaders” are referred to as people with:
“…skills like the ability to see the big picture, to think and plan strategically, to share a vision with others, and to marshal constituencies and coalitions for action”. (Roper, 1994: 16) 
Leadership is often presented as a success factor that must be present from the beginning of a whole-of-government initiative. However, some studies have emphasized the necessity of developing strong leaders and building organizational capacity over time.  The role of formal versus informal leaders has been highlighted by several studies. Informal leaders can play an important role in facilitating change.  The role of formal leaders (appointed or elected) has also been documented in whole-of-government approaches. For example, in 1998, the United Kingdom government created the position of Cabinet Enforcer to strengthen joint working within government. The Cabinet Enforcer’s main responsibility was to coordinate the work of government and avoid fragmentation and omissions between ministries.  While it appeared that the Cabinet Enforcer had unlimited access to the Prime Minister, some analysts suggested that the position did not have significant power and authority. ,  Two cabinet members served as Cabinet Enforcers in the United Kingdom between 1998 and 2001, after which the position was abolished.
One lesson from the United Kingdom’s experience and other studies is that enforcement through a statutory duty to collaborate may be necessary for the success of whole-of-government approaches.  At the very least, lines of authority should be clearly delineated  with enough formal details on what departments are expected to do, particularly regarding substance and expected outcomes.
-The Invisible Hand: Resources, Financial Incentives, and Supporting Structures
Inadequate funding and a failure to realize that departments may have only a limited capacity to overcome interdepartmental differences (e.g. underestimating the cost of working horizontally) can act as significant barriers to cross-ministerial work.  However, while money can improve capability, too much money too early in the process can also prevent people from innovating.  Strategic timing of funding is important. Timely funding can help motivate departments and ensure that results are consistent with the objectives of the initiative.
Whole-of-government initiatives may also benefit from a management culture that relies less on command and control, and more on financial incentives, continual monitoring, and ongoing consultation and engagement.  Reward and recognition are strong incentives for cooperation and coordination and new supporting structures are sometimes needed to facilitate ongoing consultation engagement and to maintain the momentum toward intersectoral work.
Accountability is a component of governance that refers broadly to the responsibility and ability of one group to explain its actions to another. ,  Behind this fairly simple definition lies a complex and ever-expanding concept.  Accountability has an external component, in that the account is given to some other person or body outside the one being held accountable. Straightforward examples include accountability relationships between citizens and elected officials, or between elected officials and civil servants. From the external perspective, accountability relates to authority and control. As stated by Mulgan, “The core sense of accountability is clearly grounded in the general purpose of making agents and subordinates act in accordance with the wishes of their superiors. Subordinates are called to account and, if necessary, penalized as means of bringing them under control.” (Mulgan, 2000: 558) 
In addition, accountability has an internal component (also called inward or personal accountability). From the internal perspective, accountability refers to the personal exercise of judgment and adherence to internalized standards, regardless of external scrutiny or sanction, actual or potential. The concept of organizational culture becomes highly significant, based on the assumption that the desired outcome can be achieved without the use of explicit sanctions or control measures.
The literature on whole-of-government approaches and accountability is focused on external accountability. Having a clear accountability framework is deemed important to ensure the success of whole-of-government initiatives. However, in intersectoral work, clarifying the lines of accountability can be a significant challenge. Cross-cutting work involves more complex accountability arrangements, often related to overlapping accountabilities , in part because whole-of-government reporting typically exists on a level above individual agency reporting. In joined-up initiatives, various forms of reporting to Parliament exist, each one with different benefits and challenges.  For example, in the case of Ministers reporting to Parliament, accountability and its required reporting can exist in one or more of the following forms.
- When each entity answers for its own part, one-to-one relationships exist, which are simpler, but result in fragmented reporting.
- When an active participant takes the lead role, the potential for integrated reporting exists, but the role of the other minister(s) is sidelined.
- When a non-participating minister takes on a coordinating role, the potential for impartiality exists; the coordinating minister is answerable for results without having direct responsibility for the services or resources.
- When ministers answer collectively, the potential for integrated reporting exists, but there is no apparent basis for traditional individual ministerial accountability.
- When the prime minister or premier takes responsibility, the emphasis shifts to whole-of-government accountability.
According to Wilkins, the trend towards accountability for results over the past 25 years has in effect introduced the sharing of responsibility, while leaving in place traditional concepts of accountability.  It is still desirable to see a Premier or Prime Minister taking responsibility but it might not be sufficient.
While the concept of shared accountability has been growing in popularity over the past two decades, surprisingly little evidence exists about what works and what does not work. A report published during the golden years (1997-2002) of the joined-up government phase in the United Kingdom concluded that departments were given very little guidance on implementing accountability arrangements for joined initiatives. In addition, there is an evidence gap regarding the “accountability for results” movement, with some describing it as a “cat’s cradle of overlapping, competing, and unclear lines of accountability.” (Perry 6 et al., 1999: 43) 
Performance measurement may help make accountability possible. Ongoing performance measurement and periodic evaluations are key tools when implementing joined initiatives. Performance management systems may generate information that can be used as incentives to stimulate intersectoral work and to maintain momentum. Performance measurement can take different forms, each with different implications regarding accountability. It can refer only to processes and actions that address priorities (monitoring function and process indicators), or it can measure impact through targets. As reported earlier, traditional outcome evaluations are challenging in some fields, such as public health, since the benefits of intersectoral action may require several years to materialize. 
The evaluation challenge is even more daunting in joined initiatives. Typically, joined initiatives are more complex and may require longer planning and implementation phases. In the United Kingdom, one of the greatest challenges faced by managers with health-related intersectoral initiatives was that the government demanded very early evidence of impact. As a consequence, the intersectoral partnerships placed an early emphasis on recording outputs for individual projects rather than taking the time to consider how best to structure their activities to realize longer term outcomes.  A special project in the United Kingdom investigated how performance measurement influenced intersectoral work. The Measurement and Performance Project was developed to understand and improve the use of targets and performance measures in multi-agency working. Several case studies investigated whether performance measures act as barriers or incentives to multi-agency work to deliver public services. A cross-case analysis found that 1) performance targets act as incentives to partnership working when they support shared aims and objectives; 2) greater coherence is needed between national, regional, and local organizations when agreeing to high level targets; and 3) targets must be set against baselines using robust information. 
Some lessons learned from whole-of-government approaches are that one size does not fit all  and that using a whole-of-government approach may not be appropriate in all circumstances or for all public sector activities. At least two crucial questions remain: What governance and coordination mechanisms work best for effective intersectoral action and cross-ministerial work, and in what context? What are the essential components of an effective accountability framework for whole-of-government initiatives? Providing credible answers to these questions requires more interdisciplinary research on governance and accountability. In that regard, a report from the Alliance for Health Policy and Systems Research notes that research on governance and accountability has been neglected so far, and only limited knowledge is available to inform policy and practice.  The ActNowBC initiative provides us with an opportunity to contribute evidence to answer these questions for whole-of-government initiatives in the field of public health.
2The concept of coordination is used interchangeably with integration by some authors, but distinctively by others. To some observers, whole-of-government approaches refer more to integration (includes joint implementation) than coordination (includes dialogues and joint planning but is stopping short of joint implementation). Semantics aside, both terms refer to a spectrum of activities involving different sectors of government.
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