Factors shaping intersectoral action in primary health care services

Objective: To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Methods: Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. Results: The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. Conclusions: While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Implications: Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action.     

Understanding the challenges of intersectoral action in public health through a case study of early childhood programmes and services

After two decades of intersectoral public health action, the literature reports considerable ongoing difficulty in achieving this aim. This article analyses two of the challenges of intersectoral action: (1) ensuring convergence among the interests and resources of sectoral actors, and (2) coordinating the multiplicity of sectoral programmes. A case study employing Actor–Network Theory is used to provide an in-depth understanding of the persistence of these problems. In 2008, the Montreal Directorate of Public Health in the province of Quebec, Canada, implemented a vast consultation and mobilization process to address problems highlighted by the Survey of the School Readiness of Montreal Children. The process mobilized regional and local multi-sectoral actors in order to propose solutions. At the local community level, the process resulted in increased coordination leading to intersectoral innovation, while at the regional level it brought about the deployment of additional resources, albeit in sectoral programmes. This study analyses how intersectoral issues raised by the survey have been addressed so as to produce these results. It discusses how the balance between sectoral interests and the common good, as well as between sector autonomy and interdependence, is central to dealing with these two critical challenges.     

The Cuban experience in public health: does political will have a role?

The role of political will in public health has been largely ignored. In Cuba, however, for the past 50 years, political will has been the ultimate, encompassing intersectoral action in public health. The excellent achievements in population health in Cuba during these 50 years have been widely recognized. Researchers have sought to explain this "Cuban paradox" by focusing on a large array of public health factors, including health promotion, primary care activities, and intersectoral action on health determinants. These factors constitute necessary but not sufficient conditions to achieve good health outcomes. This article defines political will and uses the experience of Cuba to illustrate the potential role of political will in public health. The authors suggest a framework for the evaluation of political will aimed at achieving good health, examining the "Five R's of political will," five observable features that may provide systematic information on the direction and realization of political will: (1) renewal of commitment, (2) reform of the system, (3) resource development, (4) review of performance, and (5) responsible management. These five features focus the spotlight on the consistency between health goals and public discourse and action.     

Beyond leadership: Political strategies for coordination in health policies

Health in All Policies (HiAP) promises to improve population health by harnessing the energies and activities of various sectors. Nevertheless, it faces well-documented bureaucratic obstacles and appears to require intersectoral governance if it is to be established. The basic problems of establishing intersectoral governance for HiAP are known to public administration and political science. On reading that literature, we find that the difficulty of establishing intersectoral governance for HiAP breaks down into two kinds of problems: that of establishing coordinated actions at all (coordination); and ensuring that they endure in changed political circumstances (durability). We further find that policymakers’ solutions fall into three categories: visible ones of political will (e.g., plans and targets); bureaucratic changes such as the introduction of Health Impact Assessment or reorganization; and indirect methods such as data publication and support from outside groups to put pressure on the government. It can seem that Health in All Policies, like much of public health, depends on effective and committed policymakers but is vulnerable to changing political winds. The three kinds of strategies suggest how policymakers can, and do, create intersectoral governance that functions and persists, expanding the range of effective policy recommendations.     

Using community-based participatory approaches to mobilize communities for policy change

The Racial and Ethnic Approaches to Community Health (REACH) Alabama Breast and Cervical Cancer Coalition used community-based participatory research principles to address breast and cervical cancer disparities among Alabama's most vulnerable African American communities. With funding from the Centers for Disease Control and Prevention, the Alabama Breast and Cervical Cancer Coalition implemented a multilevel action plan, which entailed disseminating evidence-based strategies to community organizations interested in addressing cancer and other health disparities. Based on the Alabama Breast and Cervical Cancer Coalition's technical assistance on advocacy, an independent, community-led coalition was formed. This article uses a case study approach to document the steps taken by this empowered coalition to mobilize their community to impact cancer disparities using community-based participatory research principles as a tool to change tobacco and breast and cervical cancer legislation.     

Health in All Policies--all talk and little action?

For three decades, Canadian and international researchers have been suggesting that improving population and public health requires attention to a range of determinants and factors and that concerted and coordinated action on the part of non-health ministries and organizations might be necessary to achieve this goal. Suggestions have been made for collaboration and integration by explicitly designing intersectoral actions and interventions and assessing the impact of all policies and programs for their effects on health. While some progress has been made on these goals, it is minor compared to the size of the problem. This article addresses one type of intersectoral action, Health in All Policies (HiAP), and asks questions about why it has not gained a place in governments across Canada. Possible barriers are suggested, such as current structural and political factors that prevent long-range, shared strategies to improve health. Suggestions are made for generating economic and evaluative data on HiAP, developing more sensitive tools for measuring HiAP and adopting explicit "trans-sectoral" approaches to policy-making.     

How does community context influence coalitions in the formation stage? a multiple case study based on the Community Coalition Action Theory

Background  

Community coalitions are rooted in complex and dynamic community systems. Despite recognition that environmental factors affect coalition behavior, few studies have examined how community context impacts coalition formation. Using the Community Coalition Action theory as an organizing framework, the current study employs multiple case study methodology to examine how five domains of community context affect coalitions in the formation stage of coalition development. Domains are history of collaboration, geography, community demographics and economic conditions, community politics and history, and community norms and values.     

超越领导力：卫生政策协调的政治策略

＂将健康融入所有政策＂是指通过发挥不同部门的优势和积极性以改善人群健康状况。然而,在具体实施的过程中会面临各种官僚制度障碍,需要进行跨部门治理,而其中涉及的基本问题已经在公共管理学和政治学领域做过阐述。通过查阅文献发现,建立＂将健康融入所有政策＂跨部门治理的难点被分解为两大类问题：一是在所有部门中开展协调性行动（协调性）,二是确保这些部门可以适应不同的政治环境（持续性）。本文还发现,决策者的应对策略也可以归纳为三种类型：明显的政治意愿（如各种计划和目标）、官僚制度改革（如引进卫生影响力评估或机构重组）以及各种间接策略（如各种数据发布以及从外部组织获得支持以向政府施加压力）。由此可以看出,与众多公共卫生政策一样,＂将健康融入所有政策＂也要依赖于可以做出并有效履行承诺的决策者,但这在不断变换的政治环境中往往不堪一击。三种应对策略则暗示了决策者该如何建立一种跨部门的治理制度,以扩大有效政策建议的范围。     

Reducing diabetes health disparities through community-based participatory action research: the Chicago Southeast Diabetes Community Action Coalition

To address disproportionately high rates of diabetes morbidity and mortality in some of Chicago's medically underserved minority neighborhoods, a group of community residents, medical and social service providers, and a local university founded the Chicago Southeast Diabetes Community Action Coalition, a Centers for Disease Control and Prevention REACH 2010 Initiative. A community-based participatory action research model guided coalition activities from conceptualization through implementation. Capacity building activities included training on: diabetes, coalition building, research methods, and action planning. Other activities sought to increase coalition members' understanding of the social causes and potential solutions for health disparities related to diabetes. Trained coalition members conducted epidemiologic analyses, focus groups, a telephone survey, and a community inventory. All coalition members participated in decisions. The participatory process led to increased awareness of the complexities of diabetes in the community and to a state of readiness for social action. Data documented disparities in diabetes. The participatory action research approach (a) encouraged key stakeholders outside of the health care sector to participate (e.g., business sector, church groups); (b) permitted an examination of the sociopolitical context affecting the health of the community; (c) provided an opportunity to focus on preventing the onset of diabetes and its complications; (d) increased understanding of the importance of community research in catalyzing social action aimed at community and systems change and change among change agents.     

Weight of the evidence or wait for the evidence? Protecting underground miners from diesel particulate matter

A coalition of mine operators has used a variety of tactics to obstruct scientific inquiry and impede public health action designed to protect underground miners from diesel particulate matter. These workers are exposed to the highest level of diesel particulate matter compared with any other occupational group.This case study profiles a decade-long saga of the Methane Awareness Resource Group Diesel Coalition to impede epidemiological studies on diesel exhaust undertaken by the National Institute for Occupational Safety and Health and the National Cancer Institute, and to derail a health standard promulgated by the Mine Safety and Health Administration. The case study highlights the coalition's mastery of legislative, judicial, and executive branch operations and the reaction of policymakers.     

Report from the Field: Promoting Youth/Adult Partnerships: The Seven Circles Coalition in Sitka, Alaska

The purpose of this Report from the Field is to describe a regional substance abuse prevention coalition in Southeast Alaska, that has thoroughly integrated a youth/adult partnership model. The principles and key components of the youth/adult partnership model are described, followed by an overview of how this model has been incorporated at the community level, and some of the lessons learned. Since 1994 the Seven Circles Coalition has worked with eleven Southeast Alaska communities to develop and support partnerships that provide youth-focused prevention services using a youth/adult partnership model. Each of these local partnerships serves as a model for other potential youth/adult partnerships in their respective communities.     

Needle plan defeated

The Worcester, MA, city council rejected a needle-exchange and drug treatment program proposed by a coalition of HIV prevention groups. The Harm and Risk Reduction Coalition plan was also opposed by the Christian Coalition of Massachusetts. One councilman voted against the plan because he said his constituents opposed it. This was the second defeat for needle-exchange programs in the town.     

The ambiguities of the ‘partnership’ between civil society and the state in Uganda's AIDS response during the 1990s and 2000s as demonstrated in the development of TASO

This article critically investigates state–civil society relations in the Ugandan AIDS response by tracing the history of Uganda's ‘multisectoral’ and ‘partnership’ approaches, particularly as it pertains to The AIDS Support Organisation (TASO). It finds that the Ugandan government's reputation for good leadership on AIDS is more ambiguous than commonly supposed and that the much-vaunted ‘partnership’ approach has not enabled strong critical civil society voices to emerge or prevented the harmful impact of a socially conservative agenda. By the 1990s, TASO had become the most important provider of medical and psychosocial support services to HIV/AIDS patients, but was less effective in influencing policy or holding the state accountable (because the political context prevented a more activist stance). The effectiveness of civil society has been constrained by an authoritarian political culture and institutions that discourage vocal criticism. Despite these limitations, however, state–civil society partnership did contribute to the emergence of a relatively effective coalition for action against HIV/AIDS. Donors were essential in encouraging the emergence of this coalition.     

Improving the Quality of Health Information on the Internet

Abstract

The Internet Healthcare Coalition (IHC), a nonprofit organization, believes it is possible to improve the quality of health information on the Internet without imposing new regulations and laws that limit the freedom of information providers or consumers. This article traces the history of the grass-roots development of the IHC beginning with an October 1996 FDA-sponsored public meeting. An online call to action led to the creation of the MEDWEB-MASTERS-L e-mail discussion group where important issues were debated and a community of interest developed. Subscribers felt it was important to meet in person during June 1997. At that time, it was resolved to create a coalition of health professionals, patients, industry, publishers, and Web developers with a common goal of promoting improved Internet health resources through education and self-regulation. The IHC is currently involved with efforts to help consumers and governments control health fraud on the Internet without destroying the Internet's ability to provide useful and legitimate health information. The Coalition plans to be an educational resource to support many independent efforts by members to improve the quality of health information on the Internet. In October 1998, it plans to hold its first annual meeting.     

Network analysis as a tool to assess the intersectoral management of health determinants at the local level: A report from an exploratory study of two Cuban municipalities

Intersectoral action on health determinants has long been recognized as an important factor in achieving better population health. Nevertheless, there is no process that provides empirical evidence to policy-makers on the extent of intersectoral collaboration. We aimed to fill this gap by conducting case studies in two municipalities in Cuba, a country well known for its intersectoral practice and good health outcomes. We surveyed an intentional sample of key members of Health Councils – virtual intersectoral spaces in Cuba – about links and related actions they had with other sectors on eleven health determinants. Using network analysis we were able to produce measures to evaluate and characterize the network of sectors. Findings show that the two municipalities were similar in reported importance of health determinants, extent of long-term engagement in intra-sectors actions and level of collaboration with other sectors for virtually all determinants. Municipalities also showed similar overall levels of collaboration for most determinants when considered as a network of different sectors (network density). However municipalities showed differences in the central role played by some sectors (centrality index). We further used the network analysis blockmodeling technique to typify the municipal Health Councils. We found that while one Health Council can be typified by a single well connected network structure, the other has two distinct structures with more sparse connections. We conclude that intersectoral collaboration can be assessed by the use of network analysis measurements. This approach is novel and provides evidence to decision-makers about their role and their effort towards collaboration in achieving better health outcomes.     

The pursuit of political will: politicians' motivation and health promotion

The health promotion literature points out a significant gap between declared health promotion policy and practice. The common assumption is that one of the main obstacles to progress is “political will” and the intersectoral action necessary to create healthy environments. The concept of political will is most frequently invoked to explain a lack of action usually rooted in politicians' lack of personal courage or good sense. While stressing the fact that health and its promotion are profoundly political, we claim that the lack of political will is usually not because politicians have shown insufficient personal courage or good sense. Rather, we suggest that one of the reasons for the gap between the need for health promotion policies and political will derives from politicians' lack of attraction to several aspects associated with this policy area. In many cases, politicians are not attracted to the issue of health promotion because of the unique structural conditions usually associated with this policy domain. Using tools related to public policy theory, we suggest a conceptual framework that explains what those conditions are and answers the question of why politicians seem to lack the political will to undertake the design of health promotion policies. Copyright © 2013 John Wiley & Sons, Ltd.     

Intersectoral policies to meet the challenge of active aging. SESPAS report 2010

Population aging is accelerating rapidly in Spain, posing challenges and creating opportunities for the active aging of future generations. Currently, the deep economic crisis and the complex political situation form the background to the debate on policies that will influence the life conditions of the elderly of the current and future generations: pensions, retirement age, and the care of dependent people. The present article reviews some aspects of the situation in Spain that can act as barriers or catalyzers for intersectoral action to achieve active aging in our country. The conditions that may influence the success of these actions are identified, and some public policies for intersectoral actions that could promote active aging in Spain are suggested.     

Applying a basic development needs approach for sustainable and integrated community development in less-developed areas: report of ongoing Iranian experience

INTRODUCTION: Despite considerable achievements in the provision of basic developmental facilities in terms of drinking water, access to primary healthcare services, high-quality and nutritious food, social services, and proper housing facilities, there are many rural and slum communities in Iran where these essential needs remain unfulfilled. Lack of equity is prominent, as large differences exist in underprivileged provinces. New policies developed in the past two decades have resulted in substantial achievements in meeting population needs and reducing the socio-economic gap; nevertheless, poverty levels, unemployment due to a large increase in the birth rate in the early 1980s, and lack of community participation are matters yet to be addressed. To overcome these deficiencies, a basic development needs approach was adopted to promote the concept of community self-help and self-reliance through intersectoral collaboration, creating an environment where people could take an active part in the development process, with the Iranian government providing the necessary support to achieve the desired level of development. DESCRIPTION OF THE PROJECT: Following firm commitment from the Iranian government and technical support from the World Health Organization Regional Office, basic development needs was assigned a high priority in health and health-related sectors, reflected in the third National Masterplan (2001-2005). A comprehensive intersectoral plan was designed, and pilot projects were commenced in three villages. Each village elected a representative, and committee clusters were formed to run and monitor projects identified by a process of local needs assessment and priority assignment. In each region, a variety of needs were elicited from these assessments, which were actively supported by local authorities. LESSON LEARNED: A basic development needs approach was found to be a reliable discipline to improve community participation, needs-led resource allocation and intersectoral co-operation in community development, particularly in underprivileged areas. Iran's initial experience of basic development needs has gained widespread public support but will require periodical evaluation as it is introduced into other rural and urban regions across the country.     

A community view of smoking cessation counseling in the practices of physicians and dentists.

The practice norms of community physicians and dentists in the Lehigh Valley of Pennsylvania for counseling about smoking cessation were surveyed. In addition, 1,373 residents in the valley were interviewed by telephone about the smoking counseling behaviors of their dentists and physicians. These activities were conducted as part of the planning for an intervention by the Coalition for a Smoke-Free Valley, a coalition of 100 persons and organizations in the area. The survey response rate for 172 physicians was 77 percent, and for 103 dentists, it was 76 percent. More physicians than dentists advised patients to quit, counseled patients, provided materials, and helped the patient to set a quit date. However, there was a clear discrepancy between what physicians say they do and what smokers say they hear.