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