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

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Acknowledgements

The authors wish to acknowledge the significant contribution to this paper by Lucy Gilson and Jane Doherty of the Health Systems Knowledge Network (HSKN) of the WHO Commission on Social Determinants of Health (SDH). In particular, thank you to the Regional Network for Equity in Health in East and Southern Africa (EQUINET) for conducting extensive research to identify sources used in this review and to Jane Doherty and Bronwyn Harris for summaries of key documents and experiences. Both Lucy and Jane provided helpful comments and advice on the outline and earlier drafts of this synthesis. Members of the HSKN generously shared insights into their experiences with intersectoral action for health and equity. Thanks to Nicole Valentine, Alexandra Nolen, Orielle Solar and Jeanette Vega of the Secretariat of the WHO Commission on Social Determinants of Health for providing materials and comments to shape this synthesis and analysis.

Preface

This paper was written for the Health Systems Knowledge Network (HSKN)¹ established as part of the WHO Commission on the Social Determinants of Health, and was reviewed by at least one reviewer from within the HSKN and one external reviewer. Thanks are due to these reviewers for their advice on additional sources of information, different analytical perspectives and assistance in clarifying key messages.

Executive Summary

This paper represents the first phase of a Canadian initiative on intersectoral action for health and provides an overview of approaches to intersectoral action at the global, sub-regional, national, sub-national, and community levels. It is intended to contribute to the World Health Organisation's Commission on Social Determinants of Health (SDH) and is the result of collaboration between EQUINET, the Health Systems Knowledge Network of the Commission on SDH and the Public Health Agency of Canada.

Experiences documented by academics, policy-makers and practitioners in more than 15 countries are examined in an attempt to improve understanding of questions relating to:

• the types of problems addressed through intersectoral action (IA);
• the conditions that shape horizontal and interjurisdictional collaboration;
• tools, mechanisms and approaches to support IA; and
• roles played by the health sector and other actors.

As evidenced in this paper, the experience of intersectoral action offers significant lessons to draw upon:

• Context matters. The broader context for decision-making (political, economic and socio-cultural) affects how issues are framed and the choice of approaches (including intersectoral action), mechanisms and tools to address the problem. Variables include the stability of the socio-political environment, national income level of the country, decision-making styles and timing (e.g., pre- versus post-election). Political and civil society actors are key drivers of intersectoral action.
• IA is a strategy that can address a wide range of health problems. IA has been used to address a wide range of health and socio-economic public policy challenges, including action on specific determinant(s) of health, populations, communities, diseases and health behaviours, and risk factors. To a lesser extent, broad policy frameworks that explicitly address health equity (e.g., UK, Sweden) have outlined IA as a key strategy. The use of health equity as an explicit goal varies considerably. Issues have been framed as health promotion, disease prevention, health protection, public health, primary care, community development, crime prevention, public security, economic development, social cohesion, education, employment and sustainable development.
• Intersectoral action is both dynamic and resource-intensive. Experience in acting across sectors demonstrates that the nature of IA efforts changes throughout the policy development, implementation, and evaluation phases. The roles, actors, skills and resources required to initiate IA are very different from those required to implement the action and to assess its impact. IA has been extremely resource-intensive, in terms of people, money and time. Skills required in the development stage—e.g., negotiation and resource identification—vary considerably from those needed for implementation and assessing impacts. Defining objectives and roles, sustaining momentum, and evaluating results represent three key challenges. With these considerations in mind, a critical assessment of when, where and how to act across sectors is required.
• IA becomes more difficult in more complex policy environments. As the number of partners and interests increases, logistical challenges make it more difficult to initiate and sustain intersectoral action. More documented success stories of IA appear at the community level than at the national and global levels, and many sources acknowledge the problem of increasing complexity at higher levels of governance. The number of partners and complexity of decision-making models are likely contributing factors: a healthy community is easier to achieve than a healthy world. Yet many of the levers needed to influence large-scale improvements in health equity require intersectoral action at and between the local, subnational, national, and global levels. To be effective, IA requires a thorough understanding of the context. The complexity of decision-making needs to be viewed as an opportunity rather than a risk.

The experiences reviewed in this paper demonstrate some successes in working vertically and horizontally for health gains. Given the resource implications of intersectoral efforts, however, a critical assessment of when, where and how to act is required. While a range of approaches have been used, at different levels of governance, there does not appear to be a “one size fits all” model.

Many questions remain. The information gleaned from this paper will help shape questions to be explored in the next phase of this initiative, involving subsequent case studies and analyses and a report of country and regional experiences in IA. This paper is also expected to inform the final report of the Health System Knowledge Network (HSKN) to the WHO Commission on Social Determinants of Health.

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