Ministerial Council on HIV/AIDS

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Towards a Broader View of Health:
Strengthening Inter - Ministerial Collaboration on HIV/AIDS in Canada

Executive Summary

HIV continues to spread at an alarming rate, both in Canada and in other countries. The Ministerial Council on HIV/AIDS commissioned this paper to identify ways in which collaboration among federal government departments and agencies can contribute to the response to the HIV/AIDS epidemic. This paper is based on information gathered from a review of the literature and interviews with key informants in Canada and in eight other countries.

For the purposes of this paper, collaboration is being defined in a general sense - i.e., as encompassing a broad spectrum of ways of working together. It includes:

• ministers working together to achieve the goals of the Canadian Strategy on HIV/AIDS;
• departments and agencies working together to achieve the goals of the Strategy; and
• departments and agencies integrating HIV/AIDS into their work.

Background

Inter-ministerial collaboration on HIV/AIDS in Canada is not new. There is a history of inter-ministerial collaboration at the federal level and at the provincial-territorial level.

At the federal level, three departments and agencies have had significant involvement: Correctional Service Canada, the Canadian International Development Agency, and the Department of Justice. Other departments and agencies have been involved more peripherally. There has also been an Interdepartmental Coordinating Committee on HIV/AIDS, though it has not been very active.

Among the provinces and territories, perhaps the most interesting example of inter-ministerial collaboration is happening now in British Columbia, where an inter-ministry committee has been established, and where a number of departments and agencies have publicly identified future commitments with respect to HIV/AIDS work.

There has been inter-ministerial collaboration at the federal level in Canada in fields other than HIV/AIDS. There has also been inter-ministerial collaboration on HIV/AIDS in other countries. Lessons can be drawn from these examples and then applied to the task of strengthening collaboration on HIV/AIDS in Canada.

Making the Case for Collaboration

Other departments and agencies should be involved in the response to HIV/AIDS because they can have a fundamental impact on the epidemic.

Increasingly, health is being defined in the context of a population health approach. This approach says that health is based on much more than health care services, and that other factors impact on health. These factors are called determinants of health and include income and social status, social support networks, education, employment and working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, and gender and culture.

Viewing health from the perspective of the determinants of health makes perfect sense in the context of HIV/AIDS. HIV/AIDS thrives in areas where society breaks down and where the determinants of health are weakest. For example, people with HIV who are poor die sooner then people with HIV with higher incomes. Another example is the challenge to provide HIV prevention and care for people who are homeless. A homeless person does not have a safe space to store condoms and clean needles, or to have safer sex or safer drug use, or (if HIV+) to keep and take medications. Therefore, reducing poverty and improving housing have a positive impact on the HIV epidemic (as well as on a whole range of health issues).

These determinants of health are mostly influenced by departments and agencies other than Health Canada.

There are several other reasons why departments and agencies should collaborate in the response to HIV/AIDS:

• Some of the other departments and agencies are directly involved in the delivery of health care.
• It is often useful to bring people with different expertise together to work on an issue.
• Collaboration helps to stretch resources.
• Departments and agencies should not be working in isolation.
• HIV/AIDS work often has broader applications that can benefit other diseases and conditions.
• Collaboration is required among the departments and agencies that have international responsibilities because Canada plays an important role in the global response to HIV/AIDS.

Case Studies

Six examples of inter-ministerial collaboration were analyzed in depth for this paper:

• three cases involving collaboration on HIV/AIDS with departments and agencies at the federal level (Canadian International Development Agency, Correctional Service Canada, and the Department of Justice);
• the Interdepartmental Coordinating Committee on HIV/AIDS;
• inter-ministerial collaboration on HIV/AIDS in British Columbia; and
• inter-ministerial collaboration at the federal level in a field other than HIV/AIDS (Family Violence Initiative).

The following lessons emerged from the analysis:

• Leadership at senior levels is important to successful collaboration.
• The involvement of the Minister of Health and senior officials at Health Canada are a critical tool in bringing a department or agency on-side.
• The involvement of community-based HIV/AIDS organizations is a useful strategy for getting other departments and agencies involved.
• Continued involvement of community-based organizations will help to ensure that collaboration is successful over the long haul.
• Time and effort is required to convince a department or agency to participate and to build good working relationships.
• Once a department or agency recognizes that HIV/AIDS is integrally related to its own work, it is more likely to provide funding for HIV/AIDS programming from its own budgets.
• Sufficient resources (human and financial) need to be built into any inter-ministerial collaboration.
• Collaboration works best when it creates a win-win situation.
• Small, focussed working groups are more effective than large committees for getting work done.
• Good collaboration is proactive as well as reactive.
• Having the staff resources at Health Canada to work on inter-ministerial policy issues is a critical ingredient to collaboration.
• It is important for any inter-ministerial collaboration to have a strategic plan that incorporates the activities of the departments and agencies involved.
• Support from central agencies is important to making inter-ministerial collaboration work.
• In any inter-ministerial collaboration, resources should be available to train people from the participating departments and agencies on the issues.
• In any inter-ministerial collaboration, the role of the lead department needs to be clearly spelled out.

 

Potential Barriers to Collaboration

There are numerous barriers that prevent or weaken inter-ministerial collaboration on HIV/AIDS. At times, they can deter people from taking on the issue in a meaningful way. Some of these barriers are:

• People have become complacent about HIV/AIDS.
• Stigma and discrimination based on HIV/AIDS get in the way.
• Other departments and agencies see HIV/AIDS as just a health issue.
• Other departments and agencies have many other priorities.
• The structures and culture of government make collaboration difficult.
• HIV/AIDS is not seen as a government-wide priority.
• There is insufficient funding available to do collaboration.
• For the most part, the HIV/AIDS community is not engaging other departments and agencies.
• Collaboration within Health Canada itself is not always effective.

.Strategies for Successful Collaboration

Lessons learned from existing collaborations and input from key informants were used to identify strategies for successful collaboration.

The following strategies can help get other departments and agencies involved in collaboration:

• Obtain leadership and commitment at senior levels of government.
• Make inter-ministerial collaboration a priority within the Canadian Strategy on HIV/AIDS.
• Obtain buy-in from other departments and agencies.
• Work the system at different levels.
• Be prepared to invest time and resources.
• Provide assistance to community-based organizations to enable them to engage other departments and agencies.
• Start small and build from there.
• Consider the establishment of a non-partisan parliamentary group on HIV/AIDS.

The following strategies can help make collaboration work once it has been established:

• Appoint liaison persons and work one-on-one or in small groups.
• Be prepared to involve other stakeholders (where warranted).
• Be realistic about what can be accomplished.
• Involve other departments and agencies in the planning process.
• Make collaboration proactive (not just reactive).
• Build in accountability mechanisms.
• Design systems to ensure good communications.

The Way Ahead

How should Health Canada and the Minister of Health proceed to strengthen inter-ministerial collaboration on HIV/AIDS at the federal level in Canada? The authors of this paper recommend the following approaches and specific activities. (Please consult Section 7.0 The Way Ahead: Recommendations for a discussion of these recommendations.)

Approaches

Health Canada should consolidate its relationships with departments and agencies already involved in inter-ministerial collaboration. Health Canada should also expand inter-ministerial collaboration among new departments and agencies. It should and adopt an incremental approach and select only the most likely candidates for an initial round of inter-ministerial collaboration expansion.

As this incremental approach builds success, more and more departments and agencies will become involved in HIV/AIDS work. Ultimately, this will permit the federal government to adopt a government-wide, coordinated approach to HIV/AIDS, one that takes into account all of the determinants of health..

Health Canada should ensure that any plan it develops to expand inter-ministerial collaboration at the federal level in Canada includes three strategies that are critical to successful collaboration:

• obtaining leadership and commitment at senior levels;
• obtaining buy-in from other departments and agencies; and
• facilitating the participation of community-based HIV/AIDS organizations.

Recommendations with Respect to Recruiting New Departments and Agencies

The following specific activities are recommended:

1. Make inter-ministerial collaboration a priority in the Canadian Strategy on HIV/AIDS.
2. Make inter-ministerial collaboration a greater priority among the responsibilities of staff in the HIV/AIDS Division at Health Canada.
3. Select the departments and agencies to be targeted initially.
4. Build the case for the involvement of the targeted departments and agencies.
5. Identify funding for these inter-ministerial collaborations.
6. Use an individualized, strategic approach to the targeted departments and agencies.
7. Obtain the assistance of community-based HIV/AIDS organizations.
8. Secure buy-in at the highest levels.
9. Ensure that liaison persons are appointed in the participating departments and agencies.
10. Set objectives for each collaboration and develop workplans with the participating departments and agencies.
11. Build in accountability and evaluation mechanisms.
12. Establish working groups (where appropriate).
13. Include the participating departments and agencies in future planning for the Canadian Strategy on HIV/AIDS.

Recommendations with Respect to Enhancing Existing Collaborations

Some of the specific activities recommended above for recruiting new departments and agencies (or variations of these activities) should be applied to the existing collaborations. These include the following:

• Ensure that the staff of the HIV/AIDS Policy, Coordination and Programs Division are given appropriate support to maintain and enhance current working relationships.
• Identify any funding needed to enhance current inter-ministerial collaborations.
• Help to strengthen the relationship between these departments and community-based organizations.
• Ensure that mutual goals and plans with these departments are reviewed and accountability mechanisms are clear.
• Maintain communication at senior levels to support ongoing collaboration at programme levels.

.The following additional specific activities are recommended:

1. Conduct an evaluation of the existing collaborations.
2. Analyze the results of the evaluations and make changes where appropriate.

Other Recommendations

The authors advance the following additional recommendations:

• Health Canada should integrate HIV/AIDS into other programmes within its own department (e.g., programmes that deal with family violence, mental health and children) in order to facilitate collaboration with other departments and agencies.
• Health Canada should provide training on HIV/AIDS issues (as required) to people in other participating departments and agencies.
• Health Canada should consider developing an educational campaign on population health and the determinants of health, in order to familiarize other departments and agencies with these concepts.

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