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ENHANCING MECHANISMS FOR MULTISECTORAL ACTION – EWEC

06 ENHANCING MECHANISMS FOR MULTISECTORAL ACTION


Implementation objectives:


Governance to enable multisectoral action

Structures to support multisectoral collaboration

Joint monitoring across sectors

Multisectoral action on the determinants of health is essential to realize the vision of the Global Strategy, in particular to reduce inequities. Even for health outcomes highly sensitive to health service delivery, such as maternal, neonatal and child mortality and stillbirths, the actions of the health sector on its own are insufficient. For example, it is estimated over that half of the improvement in under-5 mortality from 1990 to 2010 was a result of efforts beyond the health sector.

The importance of multisectoral action for health has long been recognized, including being highlighted in the Declaration of Alma Ata in 1978 and more recently in the 2011 Rio Political Declaration on the Social Determinants of Health. Yet working across sectors has proved difficult in practice, needing to reconcile differences in culture, language, epistemology and accountability. The health sector has often struggled to understand the interests of other sectors and to articulate why other sectors should consider health impacts and their contribution to health. There has also been a lack of functional convergence between sectors with different strategies that impact on women’s, children’s and adolescents’ health, leading to poor implementation.

The SDGs present a more integrated agenda for development than the MDGs, and therefore provide an opportunity for countries to take a more multisectoral approach to health. In doing so it is important to distinguish between different types of multisectoral action on determinants of health:

  • addressing structural forces and social and gender norms that affect all of society, including those that drive disparities. These require wide ranging cross sectoral legislation and policies driven by heads of government and championed by key societal agents of change
  • supporting actions within single sectors that form their core business (such as ensuring children attend school and learn well for the education sector, access to safe water for the water and sanitation sector, or access to clean power for the energy sector)
  • ensuring the health sector recognises its own role in generating health disparities (such as discrimination and abuse, provision of differential quality of care to different groups, and inadequate water and energy supplies to health facilities) and maximises its key role in primary prevention
  • identifying, promoting and co-financing actions that require collaboration between two or more sectors (intersectoral work) to produce joint or “co-benefits” and to maximise health benefits (such as the use of cleaner stoves to reduce indoor air pollution or comprehensive sexuality education in schools).

Further work on the governance, financing and monitoring of multisectoral action is underway under the auspices of Every Woman Every Child, with the aim of providing further resources and technical guidance for countries to implement a multisectoral approach to women’s, children’s and adolescents’ health.

6.1 Governance to enable multisectoral action

Multisectoral action for health rarely occurs spontaneously. Countries that have had success with multisectoral action have seen political leadership and commitment from heads of government to drive and coordinate different sectors and actors to work together with joint accountability. Whether at national or subnational level, it is essential to have political leaders, to whom multiple sectors report, drive any multisectoral initiative, persistently articulating the case for why the inputs of different sectors are required. But such leadership is only the first step. Additional steps required for implementation can be summarized as follows, allowing that each country will need to adapt this for their own context:

  1. Create a policy framework and an approach to health that are conducive to multisectoral action.
  2. Emphasize shared values, interests and objectives among partners and potential partners.
  3. Raise political support; build on positive factors in the policy environment.
  4. Engage key partners at the very beginning, including civil society; be inclusive.
  5. Enable appropriate horizontal linking across sectors as well as vertical linking of levels within sectors.
  6. Invest in the alliance-building process by working towards consensus and accountability mechanisms at the planning stage.
  7. Focus on concrete objectives and visible results.
  8. Organize for leadership, accountability and rewards to be shared among partners.
  9. Build stable teams of people who work well together, with appropriate support systems.
  10. Develop practical models, tools, mechanisms and accountability frameworks to support the implementation of multisectoral action.
  11. Facilitate public participation; educate the public and raise awareness about health determinants and multisectoral action.
  12. Mobilize sufficient financial and interdisciplinary human resources for implementation.

6.2 Structures to support multisectoral collaboration

Multisectoral collaboration depends on shared understanding and interests, driven by supportive and joint accountability. Structures by themselves cannot ensure the success of multisectoral efforts, and the creation of structures, absent the necessary supportive environment, often generates redundancy.

At the same time, in the context of a supportive environment, there are a number of structures and tools that can be useful to implement multisectoral work. These include:

  • inter-ministerial and interdepartmental committees
  • cross-sector action teams
  • integrated budgets and accounting
  • cross-cutting information and evaluation systems
  • integrated workforce development
  • community consultations and Citizens’ Juries
  • partnership platforms
  • health and health equity lenses
  • impact assessments
  • legislative frameworks.

 

6.3 Joint monitoring across sectors

The Global Strategy itself provides an impetus for joint monitoring across sectors, as its targets are multisectoral. These are concentrated in the “Transform” dimension, but are also integral to achieving the “Survive” and “Thrive” dimensions. Taking this cue, national strategies can monitor the inputs to health across key sectors, harnessing existing monitoring initiatives in other sectors—such as nutrition, water and sanitation—to deliver joint information and accountability while facilitating cross sectoral analysis and prioritization for investment and implementation. For example, national health strategies should consider rates of enrollment and attendance of adolescent girls in education as much as they consider adolescent pregnancy and immunization coverage rates. This does not mean that the health sector should be responsible for monitoring outcomes outside its purview. Nor does this does mean that the responsibility for education of adolescent girls lies with the health sector. Instead, all sectors need to consider their accountability for contributions to health and monitor their impact on health outcomes. National strategies on the health of women, children and adolescents should convene the key sectors who contribute to impact, for which ministries of health can play a convening role.

Tools and methods are available for analyzing health and equity risks and benefits associated with policies implemented across and within different sectors (such as “health in all policies” and health impact assessment) and to review specific determinants (such as gender assessments and audits and gender responsive planning and budgeting).

CASE
STUDY

Chile’s Crece Contigo Programme: A case study on effectively using multisectoral action to improve early childhood development

Chile is a middle-income country with low infant mortality (8.3 per 1000 live births) and broad health coverage, but Chile still faces important inequities in education, wealth distribution and health. In the 1990s, with sustained political commitment to equity, Chile began to strengthen social policies to address inequities in living conditions of the people. In that decade, specific equity-oriented programmes on education, health and housing proliferated, but programmes were often limited to their own sector and missed opportunities to harmonize and augment other programmes. By the 2000s, Chile recognized the need for a multisectoral action to effectively tackle complex social and health inequities. New policy strategies maintained the explicit focus on equity and prioritized expanding the sectors that needed to participate in social interventions; the President lent strong political support to this work. At the same time, in 2005, Chile underwent health system reform. The shift in policy focus from the 1990s to the 2000s, the explicit policy focus on equity and health system reform effectively set the stage for the landmark social protection system to foster early childhood development, Chile Crece Contigo (ChCC).

ChCC is a human rights- and evidence-based social protection system aimed at eliminating socioeconomic differences between children from gestation through pre-kindergarten. From its start, a presidential council sought regional, national and international input from experts, civil society and community actors across sectors. By 2007, new initiatives were introduced, providing universal access to parental protection, nursery and pre-school, improved prenatal care, birth with paternal participation and improved well child care, all with added support for vulnerable families.

This ambitious agenda was feasible only through multisectoral action: The first stage of implementation began with creating a Coordinating Team (part of the Social Determinants of Health and Health Equity Secretariat) within the Ministry of Health. ChCC continues to be characterized by close collaboration between the Ministries of Planning and Health, sustained political support and municipal implementation through local inter-sectoral networks. Specifically, in 2009, ChCC was made mandatory in all municipalities. An accompanying decree established a Committee of Nine Ministers, including the Ministers of Planning, Health, Education, Justice, Women’s National Service, Finance, Presidency, Labor and Housing. The national technical committee was expanded to include all public services related to children, and a permanent working group was established. Implementation at the Regional level is coordinated by a Regional Cabinet and led by the Regional Ministerial Secretary of Planning, while the Director of each municipal Health Service Unit serves as territorial manager of the Local Intervention Network (the primary care center serves as the entry point for families).

The Registry Monitoring and Reference System (SDRM) was established with participation of all sectors in order to monitor and evaluate every child from entry in prenatal care to four years of age, measuring process, intermediate results and impact. SDRM’s software is accessible to all actors linked to the programme, facilitating immediate access to benefits. Since its inception, more than 650,000 pregnant women entered into ChCC, and in 2012, more than 638,000 home visits were made to vulnerable families. Since 2009, every child born in Chile receives a set of basic childcare aids. In response to its own aspirations for child development, Uruguay launched Uruguay Crece Contigo in 2012, modeled after ChCC.

Source: Vega J. Steps towards the health equity agenda in Chile. Chile Crece Contigo. http://www.crececontigo.gob.cl/
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