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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