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Increasingly, departments, agencies, and other actors recognise the need to work across sectoral and organisational boundaries to achieve results. Experiences reviewed demonstrate two major lessons emerging from horizontal work:
Intersectoral initiatives do not necessarily save time or money. Governments and other organisations should think carefully before embarking on such initiatives, and be prepared to see them through when they do proceed. While different nations and levels of government have taken various approaches to intersectoral action, the literature has yielded some broad implications. Six issues are discussed below: achieving policy coherence, focusing intersectoral efforts, sustaining commitment, strengthening capacity, balancing competing objectives and interests, and accounting for results.
As many sectors engage in IA, there is a corresponding need to ensure that government policies are aligned with broad, shared objectives. This requires sensitivity to the range of actors, policy options, and opportunities for collaboration, with significant implications for organisational or initiative design and resource allocations within the health sector.
The formulation of coherent policies involving multiple sectors may include incentives for IA collaboration, articulated by the highest levels. Such incentives have a greater chance of succeeding and overcoming competition among sectors when they are accompanied by active financial support and clear-cut budget appropriation for IA (Rachlis 1999). Government policy reviews aimed at harmonising policies, while cumbersome, could yield a sustainable process with long-lasting impacts. Such reviews may also identify policies that are working at cross-purposes.
Witness the Millennium Development Declaration, adopted by 170 heads of state in 2000, which has produced Millennium Development Goals (MDGs). These goals represent the first global policy framework for poverty reduction adopted at a level where “sectoral divides can be overcome and opportunities for collaborative approaches enforced”. However, Bos concludes that success is still limited despite the presence of the framework (2006).
Given the resources and time required to support many intersectoral efforts, and the challenges associated with measuring their impact, the literature appears to advocate selective, pragmatic approaches to IA. Both New Zealand and the Netherlands have identified feasibility assessments as a means of assessing and prioritising proposals for new intersectoral initiatives or policies (New Zealand Ministry of Health 2001, p. 139), (van Herten et al. 2001, pp. 343-345). Van Herten et al. note that the “feasibility of [intersectoral health] policy depends of the availability of evidence, the degree of support and the availability of tools for implementation” (2001, p. 345). Consciously choosing when, where, and how to work across sectors is a way to ensure that resources are focussed where they are likely to have the most impact, and where conditions for success exist.
The level of engagement that is selected may range from monitoring of opportunities to joint programming or shared evaluation models. Collaboration may be appropriate only at the policy development and evaluation stages; implementation of sectoral elements of a shared policy framework may be sector-specific. This refinement—i.e., thinking about where, when and how to engage—may represent a natural evolution building on the experiences of past intersectoral work. A cautionary note is required, however. Some of the most difficult policy challenges, such as health equity, may require sustained efforts by multiple actors over long timeframes to realise results. Intersectoral action needs to be directed toward objectives; it should not be determined by the ease of working with specific sectors. Tangible results, in the short- and medium-terms, toward overarching goals may depend on collaboration with sectors that share interests with the health sector.
Garnering shared support and sustaining commitment for intersectoral initiatives are important factors in the success of such plans. Because IA tends to cost more and take longer than other approaches to yield results, it is essential to secure the commitment of sectors and stakeholders. The vertical orientation of most organisational reporting relationships may create tensions regarding horizontal or multi-jurisdictional action and reporting.
Sustaining commitment to IA may be problematic because there may be considerable political and bureaucratic turnover during the length of time required to complete a project. The terms of elected and unelected officials or other sectoral leaders may end before IA initiatives succeed, and changes in leadership may threaten the continuation of the collaborative work. Policies may change along with leaders, organisations may be restructured, and emergencies may arise.
The literature reviewed sets out the following methods for ensuring sustained commitment:
Although governments and academics have generally acknowledged, over the past two decades, that intersectoral action is appropriate in complex situations, implementation is lagging. A different skill set is required for intersectoral action. Various authors have sug-gested organisational capacity to initiate and implement cross-organisational initiatives as a criterion for proceeding with IA. Fulfilment of the health sector roles of leadership, partnership, support and defence requires knowledge and skills that extend beyond health issues. Health sector organisations require an enhanced and more systematic approach to understanding the social and economic environment, policy drivers, and related opportunities and risks. As noted by Stahl et al., health organisations also require the mandate and support to influence other sectors (2006).
Appropriate planning is crucial. Interdisciplinary and interorganisational planning approaches may be required to strengthen workers’ skills in developing plans that acknowledge multiple sectors. Experience underscores the importance of communications and negotiation as fundamental skills for IA. Environment and health collaborations demonstrated success in moving away from theoretical approaches toward problem-based approaches to learning. Workshops were developed, drawing on a mixture of disciplines and a range of approaches to address complex, practical policy challenges. The shift from discipline- and sector-specific theoretical approaches to problem-based learning has had a positive influence on IA professional development and training programs.
“While an assessment of the costs and benefits is necessary, in most horizontal projects there will be serious measurement problems.”
(Bakvis & Juillet 2004)
Managing policy and operations involving more than one sector requires a careful balancing of competing interests and objectives. To sustain IA, those in the health sector must think beyond their own goals, and take into account other objectives. Identifying links between health policy objectives and other sectors’ objectives is key to successful collaboration.
The health sector should strengthen its capacity to recognize the objectives of, and work more efficiently with, other sectors. Bos comments, “the parts of the health sector that would need to work directly with the agriculture sector are frequently under funded [sic], have no formal arrangements for intersectoral roles and responsibilities, and have staff with inadequate skills for intersectoral negotiation and decision-making [sic]” (2006, p. 2).
In many nations, and at many levels of decision- making, there is a heightened emphasis on demonstrating results. There are growing expectations from citizens, non-government actors and international donors that governments will be accountable for the results of their policy decisions.
Honest reporting of intersectoral actions, both successes and failures, is critical. In complex horizontal actions, it can be difficult to attribute accountability or credit success or failure. Complex files need clear goals, and should attempt to measure process and outcome. Traditionally, in government, lines of accountability run vertically, and a culture of “business as usual” can make interdepartmental, intersectoral collaboration difficult.
Designating a lead organisation for horizontal initiatives is necessary in order to clarify authority, instil accountability, and allocate adequate financing (Bakvis & Juillet 2004).
Many questions regarding accountability relationships in intersectoral action remain to be explored. Who receives credit for success or blame for failure? Should lines of account-ability flow through individual partners, or is it possible to establish systems in which stakeholders collectively share risk and reward? Clearly, joint initiatives push the limits of conventional accountability practices. Must compliance be compromised in order to work with partners? Probably not. Governments have become more sophisticated in recent years about planning and implementing horizontal approaches; they are still learning to incorporate checks and balances. Still, it seems that [they] are getting better and better at partnering, and at coming up with creative ways and means for reliable reporting (Fox & Lenihan 2006, p. 15).