ARCHIVED - Section 4 Discussion
In this section, we examine to what extent the factors and mechanisms that characterize intersectoral action stimulated by ActNowBC are similar or dissimilar to those identified in other studies on intersectoral action for health. For the horizontal dimension, we revisit the issues of governance and accountability, and how they affect sustainability. For the vertical dimension, we draw comparisons with other partnership models involving governments and NGOs. And we briefly discuss how ActNowBC compares with health promotion initiatives associated with other Olympic and Paralympic Games, although empirically – based studies of these types of initiatives are rare.
Since the launch of ActNowBC in March 2005, much effort has been devoted to animate and inspire BC politicians and civil servants to share the responsibility for this cross-cutting initiative and to take action accordingly. Below, we dissect that process and some of the structural features of ActNowBC in light of the current literature on horizontal management.
There is ample evidence in the literature indicating that bureaucratic accommodation usually follows political accommodation.  This study has highlighted the importance of high-level political leadership – by the BC Premier – during the implementation phase of ActNowBC as a whole-of-government initiative. This particular source of leadership has also been highlighted as a critical success factor for ActNowBC in a recent publication. 
In this study, we also presented evidence about other forms of leadership. Indeed, leadership refers not only to individuals and their skills and abilities to orient people and organizations in a certain direction; it can also be viewed as a “collective process”. For example, the literature on shared or rotating leadership offers some additional points for discussion. It can facilitate Intersectoral Action for Health (IAH), with the health sector not always needing to be in control, but it can also have pitfalls. 
Some key questions associated with a shared leadership model are: When is leadership most appropriately shared and how is shared leadership best developed? According to Pearce (2004), shared leadership is especially relevant for tasks that are highly complex and interdependent and that require a great deal of creativity.  From the perspective of the respondents, implementing an intersectoral approach requires tasks with all three of these characteristics.
Since its inception, ActNowBC has experienced different leadership models. A shared leadership model was in place between August 2006 and June 2008, during which time the Ministry of Health and the Ministry of Tourism, Sport and the Arts both had roles and responsibilities in promoting and managing ActNowBC. During that period, ActNowBC benefited from the presence of a Minister of State who with the Cabinet, used different incentives to encourage acceptance of joined-up work, this being shared leadership and responsibility across ministries for ActNowBC. The incentives/disincentives were mainly transactional (e.g. hold backs from Deputy Ministers for not meeting certain requirements or achieving certain targets linked to the logic models and service plans) and some transformational (e.g. symbolic emphasis on commitment to a shared vision, emotional engagement, and desire to engage in breakthrough achievements).
The key to successful shared leadership is to have, at all times, clear understanding about who is responsible for what and sufficient time for a “stabilization” phase after a change in leadership. With ActNowBC, numerous changes in leadership and governance models in a relatively short period of time gave rise to difficulties. The empirical data confirm that enthusiasm for ActNowBC, within and outside of government, has fluctuated since 2005. Currently, ActNowBC is back to a more traditional vertical governance and leadership structure under the new Ministry of Healthy Living and Sports. The question remains whether or not a stabilization phase will begin.
The leadership of senior civil servants was also a critical success factor behind the launch of ActNowBC. Public health bureaucrats took the opportunity presented by an Olympic bid to frame health promotion as an Olympic Games legacy for the province. Once the bid was won, their influence cannot be underestimated as they were ready and able to position what was to be gained through ActNowBC in terms of political visibility, the potential savings to the provincial budget as well as the benefits to population health. On the strength of their arguments, the Premier came on board when the bid was won and internal and public Cabinet support was from then on consistently transmitted and paved the way for the breadth of intersectoral collaboration at the heart of ActNowBC.
Civil servants with what Perry 6 et al call a “pinball” career  played an important role in ActNowBC. They have a skill set particularly effective for intersectoral action, being intentionally and systematically involved with multiple ministries. During the implementation phase of ActNowBC, one civil servant with a dual appointment to the Ministry of Health and the Ministry of Tourism, Sport and the Arts, went from ministry to ministry providing assistance in defining outputs and outcomes in the logic models that corresponded to the targets and goals of ActNowBC.
This case study contributes evidence that a broad leadership base is essential to the success of whole-of-government initiatives. The senior civil servants involved in the launch and implementation of ActNowBC have shown the capacity to do what some sociologists call “a skilled bricolage”, i.e. to use ingeniously whatever resources are at hand.  They showed leadership in making the most out of the opportunity provided by the 2010 Olympic and Paralympic Games in Vancouver:
“… The leader’s function is…fixing things on the spots through a creative vision of what is available and what might be done with it.” (Thayers, 1988, p. 239) 
Setting and monitoring health targets is one way in which government provides leadership, guidance, and strategic direction to the health sector or to whole-of-government initiatives in pursuit of healthier populations.  While the pragmatic SMART conditions for targets are well known (Specific, Measurable, Achievable, Realistic and Time-constrained), ,  setting evidence-based public health targets is a complex enterprise that requires expertise from all public health disciplines. Even the literature is divided over the extent to which health targets can be “evidence-based.” For some public health specialists, targets are a mixture of “dreams, science and political reality.” (McCarthy, 1999), 364:1664) 
The ActNowBC targets are specific, measurable, and time-bound. However, respondents disagreed about whether some targets were realistic and achievable. Recognizing that setting health targets is always a highly political affair with associated risk, some public health specialists advise not to put time and resources into technical target formulating, but instead to define visible indicators to trends that are political by nature.  One could question whether targets should be the basis for accountability to the public and for cross-ministerial performance. Nevertheless, the respondents seemed on the whole to have accepted the targets, albeit as very ambitious, understanding that they are intended to encourage innovative thinking and to challenge each government sector to accomplish more for health promotion, while at the same time demonstrating to the public the government’s good intentions to achieve a health legacy. In research after 2010, it will be important to explore the consequences, if applicable, of not achieving one or more targets.
Specific to internal accountability for reaching the targets, some but not all literature on whole-of-government approaches suggests that having a clear accountability framework as early as possible is an important factor for success. ,  It is especially critical that all stakeholders have a clear understanding of their roles and responsibilities; otherwise, accountability is weakened, and achieving organizational objectives is threatened. 
The ActNowBC accountability framework was not clarified quickly – it took several years for the framework to emerge. While some may see this as less than ideal, Perry 6 et al. (1999), reporting on holistic government in the United Kingdom, concluded that coordination and integration could be extinguished quickly by establishing rigid systems of measurement and accountability early on.  Perry 6 stated that:
“(…) better by far is to encourage continual strategic conversation about outcome measures, targets, systems of monitoring and accountability. Public managers should be encouraged to develop their own outcome measures. This can sometimes be hard for politicians who may suspect that such self-regulation merely lets officers off the hook. But as we have learned, machismo in setting rigid forms of accountability too early turns out to be the enemy of effective holistic working.” (Perry 6 et al., 1999: 44-45)
Apart from timing, defining clear accountability frameworks is difficult when devising whole-of-government strategies, since cooperation across sectoral lines inevitably blurs the traditional boundaries of budget allocation, dispersal, accounting, authority, and responsibility.  Wilkins noted that the literature has no models about how to deal effectively with overlapping accountabilities. Some literature suggests that, instead of accountability mechanisms focusing on inputs and outputs, the emphasis should be on reporting against broader performance indicators designed to measure progress toward targets and outcomes. 
Within this frame, we believe that ActNowBC is a hybrid model. With the logic models, each ministry is defining inputs and outputs, while at the same time responsibility is nurtured for achieving the broad ActNowBC goals, involving continuing communications with, for example, the Cabinet and the Assistant Deputy Ministers Interdepartmental Committee.
It remains to be seen how the current accountability mechanisms and strategies for ActNowBC – the stretch targets, logic models, service plans, and how they were developed – will contribute to the sustainability of the initiative.
There is a growing body of literature about the significant roles that NGOs can play in supporting intersectoral action for health. ,  But while their role is well documented there is less evidence about the partnership models between government authorities and NGOs that are effective in the field of health promotion for the longer term. The selection of a funding model remains a key issue.
Several international experts suggest the ongoing use of earmarked taxes on tobacco or alcohol to support health promotion efforts. This way, funding for health promotion is not directly competing with other claims, such as high profile acute care services, on the health budget in the budget bidding processes. The International Network of Health Promotion Foundations also advocates the use of Acts of Parliament to secure sustainable funds for health promotion initiatives. 
In BC, health promotion has now been separated from acute care by virtue of the creation of a Ministry of Healthy Living and Sports with a health promotion mandate apart from the Ministry of Health Services. The extent to which this mechanism secures funding for health promotion, compared to a taxing scheme, remains to be seen. In the case of ActNowBC, the BCHLA has played and continues to play an important role in the areas of advocacy for health promotion policy and the delivery of community-based programs. But the relationship between the BC government and the BCHLA can be referred to as an opportunistic partnership in that the $25.2 million grant to the BCHLA was one-time. However, the BCHLA is now advocating the creation of a permanent Health Promotion Fund to target disadvantaged British Columbians, suggesting an annual injection to the Fund of $10 million from the BC Government . A Coalition for Health Promotion that is part of the International Network of Health Promotion Foundation, but that is not directly related to ActNowBC, is also advocating the creation of an arm-length health promotion foundation that would facilitate and support community-based health promotion initiatives in the province. They envision that funding could come from two sources: 1) $1.00 per person per year (from the tax base), the equivalent of $4.3million in 2007 or 2) a one-time permanent endowment of $25 million from the BC government. 
There is no indication, at the moment, that the BC government is moving towards establishing a permanent funding transfer from the government to the NGO sector. However, the documented achievements of ActNowBC with the NGO sector may well become a critical factor in shaping the future of NGO-led public health and health promotion initiatives in the province.
The idea of using the Olympic and Paralympic games to leave a “health legacy” is not new. For example, the 2004 Athens Olympic and Paralympic Games saw several health promotion initiatives implemented. There was an emphasis on providing “smoke-free” games and many initiatives consisted of disseminating brochures with health promotion messages. The total cost of the health promotion programs of the Athens Games was estimated at 943,000 Euros; a relatively small fraction (0.08%) of the overall cost of the games.  There is similar talk of sustainable health legacies surrounding the 2012 Olympic Games in London, with an apparent emphasis on mass participation in sports, exercise and physical activity. 
Since the inception of ActNowBC, similar to Athens and what is expected with London, there is significant investment in social marketing campaigns targeting individual behaviours. Unlike Athens, ActNowBC has seen engagement of health and non-health portfolios at the government level and community-based programs have seen improvements in for example the built environment (e.g. cycling path, etc.) and school food programs. There are also promises that a wider range of policy instruments and interventions could be implemented , with a renewed emphasis, for example, on the social determinants of health.
The World Health Organization has an interest for the concept of “health legacy” not only in the context of Olympic and Paralympic Games but for all major mass national and international events. For example, discussions are ongoing about creating a health legacy for the Shanghai 2010 World Exposition.
12 The document “Healthy Futures for BC Families: The BC Healthy Living Alliance’s 2009 Budget Submission” is available here: http://www.bchealthyliving.ca/files/ BCHLA_Submission_to_the_BC_2009_Budget_Consultation.pdf
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