The roots of IA stretch back to the Alma-Ata Declaration of 1978 and the concept of Health for All, a global strategy that brought all governments and the world community together to acknowledge the social and economic dimensions of health and to collaborate in addressing health inequities. There is now broader recognition that individual determinants and their interactions exercise a powerful influence over population health. Many sectors have engaged in IA, and much has been written about their successes, near-successes, and disappointments. A concept that cast the public sector as a principal force has evolved into a strategy that embraces a range of public and private sector institutions and civil society.
Although many countries have formally committed to IA, and many sectors have risen to the challenge of working collaboratively, implemen-tation has often been flawed or neglected. Overarching goals have sometimes given way to concerns about resources, governance, and organisational mandates:
Intersectoral collaboration is not a self- generating or even a self-sustaining phenomenon. As a concept, it goes against the grain of most government systems, particularly at the national level. Ministers, usually representing specific disciplinary areas and professional groups, must defend their sector’s (vested) interests and compete with each other over limited budgets. At lower levels of government, the competitive characteristics are taken over by a perception that collaboration may actually be favourable, and at the district level the intersectoral barriers are usually non-existent. At this level, good intentions may, however, be hampered by restrictive national policies or limitations in the way earmarked funds can be spent (Bos 1998, p. 1).
There are certain sectors with which the health sector has traditionally and most fre-quently joined forces to achieve health gains. Collaborations with the education, social services, agriculture, and environmental (including water and sanitation authorities) sectors are most commonly documented in the IA literature reviewed. The justice sector may also play a role, for example, in efforts such as Australia’s National Youth Suicide Prevention Strategy.
Other sectors are noticeable by their absence. IA literature reviewed for the purposes of this paper provides little evidence of collaboration with the finance, information and communications, employment, manufacturing, transportation, and technology sectors. This may be due to the absence of intersectoral initiatives, to the keywords used in identifying materials to review, or to the limited involvement of the health sector in some intersectoral initiatives where health and health equity outcomes are identified as secondary, rather than primary, objectives.
For example, the cultural sector is increasingly viewed as a strong contributor to the health and vibrancy of cities. Cultural strategies are frequently used as instruments of social cohesion in minority or vulnerable communities. However, such initiatives may not be cited in the health literature, because they may not have an explicit health sector component. Similarly, housing initiatives in Canada, Europe and Australia, led by sectors other than health, were not captured within the scope of the IA literature reviewed for this paper. Crombie et al. offer useful commentary on this observation:
Most countries have separate policies on poverty, social inclusion and social justice. Unlike policy on inequalities in health, these policies seldom emanate from departments of health, the social inclusion/ social justice policies are motivated by a general concern for human rights and dignity, of which health is only a small part. However, as they deal with the underlying causes of inequalities in health ... they are directly related to health (2005, p. 40).
The IA literature emphasises the critical role played by political leaders in prompting and sustaining intersectoral action, either through direct involvement or liaison with senior officials assigned to the task. Most collaborations address issues or problems that are political in nature; political commitment provides both the motivation to act and the resources and structures necessary to support the action. Politicians often set the tone, at senior decision-making levels, on matters of policy direction and resource allocation. They direct and lead central agencies and line departments, which, in turn, deliver on political commitments to the electorate.
In situations where the government has clear priorities and generally supports IA, political leadership makes all the difference. But the engagement of politicians in IA also presents challenges. Conflicts may arise between Ministers about the objectives, management, and ownership of initiatives. There can be awkwardness about who takes the credit for new programs or successful interventions. These tensions may be mirrored in conflicts between departments that are expected to work together.
Other problems arise when ministers or central agencies try to dictate local priorities, or set agendas for community-based action. As a variety of sources have demonstrated, intersectoral initiatives are most successful in less complex decision-making environments, often at the community level. While politicians and ministers at the national level may be involved in supporting an initiative, planning for community-based efforts should take place “on the ground” to reflect citizens’ needs. The stability of the Health Action Zones in the UK was threatened by this type of interference. Those reviewing the New Zealand experience have noted that a combination of “‘top down’ support with ‘bottom up’ planning and management” (New Zealand Ministry of Health 2001) is required.
Strengthened intrasectoral action within the health sector has been identified by the WHO as an important component of leadership by the sector. Stahl et al. offer insights into the internal capacity that the health sector requires in order to effectively lead, influence, partner with and support other sectors:
In order to have a significant role in identifying policies and policy proposals with potential impacts on health, the health sector needs to have sufficient capacity in terms of public health personnel at the various levels of administration and this personnel needs to have adequate public health training and sufficient mandates and responsibilities allotted to them. Even if health considerations have become an intrinsic part of policy-making in some sectors, such as that of environmental policies, in general other sectors need input from the health sector in order to be able to take health implications into account. This is the case especially in areas without a strong tradition of considering health implications and in the cases of new or emerging issues or potential problems (2006, p. 276).
The health sector’s role in assessing the health impacts of policies led by other sectors may require it to defend health and health equity. The tensions associated with this role have been well documented in the development of anti-tobacco legislation, where conflict arose between economic and social partners. The health sector’s role as a defender of health, advocate of health equity, and negotiator for broader societal objectives is apparent in recent literature on health impact assessments in the EU and in the Norwegian and Finnish strategies.
At a community level, New Zealand has outlined health sector roles as follows:
Rachlis comments on the health sector’s role at the community level in connecting to community organisations:
It is at the community level that intersectoral action can be most successfully initiated and the health sector has the most influence on the decision-making process. The health sector can promote local action as well as stimulate political pressure to act on higher levels. A key step in this process is to link public health personnel with community groups. Linking public health agencies to their communities is like plugging intersectoral action into an electrical outlet. These connections provide the energy to make intersectoral action for health happen (1999, p. 21).
Working on the assumption that the most complex social problems are best resolved through intersectoral approaches, it is to be expected that the health sector will play a variety of roles in the context of different initiatives. There is, at least potentially, wide scope for intervention in areas beyond the traditional provision of health services, including research; education (of health professionals and other sectors); facilitation (community empowerment or reinforcement of positive impacts on health from other sectors); advocacy; monitoring and evaluation (of health status, impact of policies, etc.) and mediation (between conflicting interests). The sector itself is diverse, with many players in different quarters, including politicians, bureaucrats, and voluntary and private sector participants.
While the health sector must be open to working in concert with others—in fact, it often leads the charge—it must also take care not to impose its leadership in every instance. Sectors “compete” against each other because each reflects a vested interest, a certain degree of political clout, and specific territory and resources. This underlying competitiveness also exists between line departments in government.
Ministries of health play different roles depending on their governments’ stance on the matter of social determinants and the level of government support for equity goals and intersectoral action. The extent of the challenges faced by health ministers varies, depending on how divergent the views are and how supportive the climate is. In cases where the health sector must “go it alone” within government, its interactions with non-governmental organisations, civil society and private sector actors are critical to its ability to make a positive impact on health equity.
Government actors outside of the health sector hold many of the policy levers for determinants of health and health equity. Line departments responsible for environment, education, social services, housing, community and economic development are commonly cited as participants in intersectoral action for health. The sources reviewed did not provide detailed commentary on the role of these other participants in intersectoral action for health. However, it should be noted that in many of the examples, such as initiatives to address homelessness, community revitalisation efforts were led by line departments other than health. It appears that these line departments may lead, partner in, support and defend initiatives germane to their mandates.
Equity, quality of life, social and economic development are broad, cross-cutting policy goals that require collaboration among multiple line departments, central agencies, political officials, non-government and civil society in order to achieve results.
Central agencies, such as departments of finance or treasuries, play a critical role in generating and sustaining IA. Public service culture and accountability frameworks often work against collaboration and coordination. In addition to initiating horizontal initiatives on complex issues requiring the involvement of multiple departments, central agencies may play a coordination and oversight role to support intersectoral or horizontal action (Fox & Lenihan 2006).
Experience shows that there is a discrepancy between central agencies’ potential and actual roles. Central agencies have the authority and perspective to choose between competing priorities and bring different parties together. However, there is scepticism about their ability to support horizontal collaboration and facilitate the work rather than judge its results. Engaging in process may require central agencies to engage in substance—a role for which they may lack the required knowledge and capacity.
Central agencies could enhance the likelihood of success by providing greater clarity and detail on the mandate of new initiatives, the authority vested in departments or structures assigned to manage them, and the level of decision-makers to which they report. In terms of ongoing support of intersectoral projects, central agencies could play a more effective role by getting more involved in policy substance; by instituting better, more strategic financial and management procedures; and, by putting in place new accountability frameworks that reduce the reporting burden (Bakvis & Juillet 2004, pp. 64-65).
It is not evident, from the literature consulted, how central agencies view the question of health expenditures. In countries where health is uppermost on the political agenda, the primary focus is on health care delivery financing; very little attention is paid to health expenditures. Research examining the extent to which health expenditures are viewed as an investment (as opposed to a drain on the treasury) would provide useful insights.
While there are obvious tensions between line departments and central agencies over implementation and management of horizontal initiatives, Fox and Lenihan (2006) note that complex policy files demand horizontal action. Line departments and central agencies need to commit to greater understanding of the relevant dynamics, to improve the fulfilment of their respective roles. Because central agencies are viewed as playing an important role in managing the overall corporate framework, setting out incentives, and creating a supportive climate for promoting the government’s priorities, their strong commitment is required.
Non-governmental organisations (NGOs) and actors play a vital role in IA. Their growing voice and influence helps to leverage political change and action on social determinants of health. In more robust economies, their lobbying efforts can prompt governments to act. In low-income countries and fragile states, they often spearhead important initiatives and influence decision-makers. Countries such as Sri Lanka have created structures to liaise with non-governmental actors and assist in coordinating their efforts. NGOs may be the primary delivery vehicle for critical health services, or a vehicle to implement policies developed through intersectoral approaches (WHO Commission on Social Determinants of Health 2006c).
Canada’s National Homelessness Initiative, which was launched in 1999 and renewed in 2003, stands as an example of how pressure from local government and non-government actors eventually moved the federal government to act. This demonstrates the important role that actors outside government (including voluntary sector groups) can play (Canada School of Public Service 2006).
The health literature reviewed for the purposes of this paper includes little mention of the role of non-governmental organisations. The role of NGOs is explored more fully in sources dealing with international development and sustainable development. The proliferation of organisations involved in crisis response, health promotion, education, and community activism signals their growing importance as potential partners in addressing social determinants and promoting health equity. Intersectoral initiatives must take account of governance differences between NGOs and government institutions.
The degree to which NGOs’ advice and collaboration is sought by government varies from country to country; it depends, among other things, on the political climate and on their capacity to offer substantive input. The off-loading of programs and services in many western democracies has led to a growing recognition of the importance of a vibrant voluntary sector. The watchdog role played by organisations in that sector could be an interesting question to explore, as a mechanism for tracking whether, how, and by whom IA is used to address social determinants.
On a global level, the impact of private donor organisations, such as the Gates Foundation, on approaches to health and health equity is recognised. Targeted funding strategies that are disease-focused have had important impacts on patterns of health investments; in some cases, these strategies may have increased inequalities in health. The pharmaceutical industry is recognised as a significant player, but was not discussed significantly in the IA experiences reviewed.
While the importance of private sector actors is acknowledged, examples of active strategies to collaborate were not evident. The onus appears to lie with the public health sector, civil society and other actors to draw linkages between private sector interests and the benefits of health and equity.
While the media is acknowledged as playing a critical role in communicating and influencing public policy and public opinion, its role was not fully explored in the sources reviewed. This is an area that warrants further exploration.