|DR. K N RAO MEMORIAL ORATION
|Year : 2017 | Volume
| Issue : 3 | Page : 163-168
Multisectoral approach for promoting public health
Subhash Salunke1, Dharmesh Kumar Lal2
1 Senior Advisor, Public Health Foundation of India, Health Systems Support Unit, Gurgaon, Haryana, India
2 Senior Programme Manager, Health Systems Unit, PHFI, Institutional Area, Gurgaon, Haryana, India
|Date of Web Publication||15-Sep-2017|
Senior Advisor to Health Systems Support Unit, Public Health Foundation of India, Delhi NCR, Plot No. 47, Sector 44, Institutional Area Gurgaon, Gurgaon - 122 002, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Multisectoral approach (MSA) refers to deliberate collaboration among various stakeholder groups (e.g., government, civil society, and private sector) and sectors (e.g., health, environment, and economy) to jointly achieve a policy outcome. By engaging multiple sectors, partners can leverage knowledge, expertise, reach, and resources, benefiting from their combined and varied strengths as they work toward the shared goal of producing better health outcomes. Improving public health (PH) is challenging because of the size of its population and wide variation in geography. MSA help in addressing identified health issues in focused way as it helps in pooling the resources and formulating the common objectives. One of the major advantages is optimization of usage of resources by avoiding duplication of inputs and activities which tremendously improve program effectiveness and efficiency. Willingness at the leadership and mandate at the policy level are necessary to plan and execute the successful multisectoral coordination. All the major stakeholders require to share the common vision and perspective. Developing institutional mechanism is utmost requirement as it will standardize the processes of intersectoral coordination (ISC). Creation of PH cadre is strategic move to meet the major health challenges being faced by the health system, and it would be anchor of establishing systematic ISC. There are many national and international examples of MSA applications such as for malaria elimination, tobacco control, HIV/AIDS prevention, Finland's community-based cardiovascular disease prevention project (North Karelia Project), and Singapore's Health Promotion Board. Promotion of MSA within the health system and with other ministries is seen as an important measure for effective implementation and improving efficiency.
Keywords: Intersectoral coordination, multisectoral approach, public health
|How to cite this article:|
Salunke S, Lal DK. Multisectoral approach for promoting public health. Indian J Public Health 2017;61:163-8
| Introduction|| |
Multisectoral approach (MSA) refers to deliberate collaboration among various stakeholder groups (e.g., government, civil society, and private sector) and sectors (e.g., health, environment, and economy) to jointly achieve a policy outcome. By engaging multiple sectors, partners can leverage knowledge, expertise, reach, and resources, benefiting from their combined and varied strengths as they work toward the shared goal of producing better health outcomes. Public health (PH) problems are complex, and in many cases, a single health issue may be influenced by interrelated social, environmental, and economic factors that can best be addressed with a holistic, MSA. MSA also addresses important contextual factors like the social determinants of health and other determinants of behavior that, if ignored, can increase health inequalities. Implementation of Reproductive and Child Health (RCH)-I and II programs brought to the fore that there was a lack of multisectoral coordination with the line departments like Department of Women and Child Development, Rural Development, Labor and Employment and Panchayats, etc., Lack of meaningful involvement of communities and local elected bodies in planning, management, and monitoring of programs was another gap. Intersectoral Coordination (ISC) has been the one of the important components of National Health Mission (NHM) and RCH program. Within the Ministry of Health and Family Welfare (MOHFW), these linkages can be within the RCH program, such as among maternal, child and adolescent health interventions as being attempted under reproductive, maternal, newborn, and child health+, and also between RCH and other programs, on health, nutrition and education of the Departments of Women and Child Development and Education. Strengthening these linkages, which may also cover other stakeholders such as the private health sector and the voluntary sector, has the overall objective of reducing duplication and fragmentation of efforts and improving the quality of health services.
| Key Public Health Functions|| |
- Planning, program management, PH strategy development, and generating evidences for policy makers
- Preventing occurrence of disease, for example, provision of safe drinking water and sanitation facilities
- Protecting health through specific interventions, for example, immunization programs and nutritional supplements
- Promoting healthy lifestyles, for example, prevent diabetes, heart diseases, and cancer.
- Epidemic and outbreak management, for example, disease surveillance and early control measures.
| Some Key Public Health Challenges in India|| |
India has taken big strides after independence to improve the health status of its citizens, but still, it has a long way to go despite being one of the fastest economies of the world., Improving PH is challenging because of the size of its population and wide variation in geography. With the improvement in economic and other social factors the burden of diseases has changed over the years, and now it is experiencing triple burden of diseases resulting further strain on the health system.,, Further adding to this and hampering the efforts of improving the health is that majority of the population in Empowered Action Group States is having an adverse sociodemographic profile, while almost 1/3rd of population is still below poverty line. Rapid urbanization which is largely unplanned in last two decades is adding to the challenges to improve the health. Simultaneously, the health system is also facing paucity of skilled staff, particularly in difficult areas and the shortages of the specialists are more acute. Still the system of referral not very structured to ensure the continuum of care, while there is almost nonexistent accountability for the quality of care being delivered. Recurrent funding shortfalls and lack of implementation of scientific inventory management for medicines and drugs is another challenge coming in the way of delivering quality PH services in India.,
| Conceptual Framework of Multisectoral Convergence for Government Departments for Health Programs|| |
For delivering the quality health delivery services with optimum uses of resources require the participation and support of departments beyond the health sector. Hence, to improve the health indicators, other departments other than of health are required to be part of the MSA as shown in [Figure 1] below.
|Figure 1: Conceptual framework of multisectoral convergence for government departments.|
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| Advantages of Multisectoral Approach|| |
MSA helps in addressing identified health issues in focused way as it helps in pooling the resources and formulating the common objectives. Moreover, as it involves multiple sectors, it encourages participatory and inclusiveness approaches. Due to common objectives and structured coordination among all the sectors it helps in strengthening holistic program planning and implementation. One of the major advantages is optimization of usage of resources by avoiding duplication of inputs and activities which tremendously improve program effectiveness and efficiency. All these lead to avoidance of wastages of resources and improvement in the quality of services. Finally, there is optimization of outputs also.
| Implementation|| |
Willingness at the leadership and mandate at the policy level are necessary to plan and execute the successful multisectoral coordination. All the major stakeholders require to share the common vision and perspective. Developing institutional mechanism is utmost requirement as it will standardize the processes of ISC. Although the lead role is to be played by the health department but all other departments are also to be made part of decision-making to make it participatory. For smooth functioning clear cut roles and responsibilities are to be defined for all the participating stakeholders. Strategies and procedures to be defined before implementation. Monitoring and supervision are to be jointly planned so as to have coordination in the field also. There has to be an establishment of a common platform for addressing the problems and well-standardized mechanism for taking timely remedial measures in solving those problems.
As it involves many departments besides that of health, there is usually lack of common understanding of different program goals and objectives. Usually, there is unawareness about existence and launching of new initiatives among the partners as most of the time information about these are not shared. Power conflicts among stakeholders also come in the way to smooth implementation of the MSA. Human resources issues like not able to sort the seniority issues with a perfect balanced delegation of administrative and financial powers and ego related problems also lead to the bottlenecks in the implementation. Planning in isolation of Health department in relation to other relevant departments with independent budgeting and fund flow mechanism lead to conflicting and duplication of efforts which hamper the smooth implementation. Partnering departments not aware about operational mechanism of other programs create barrier during implementation stage as there is a lack of opportunities for sharing the experiences.
Identification of critical bottlenecks
- Each sector/department has its own mandate and priority (although often they overlap)
- Independent budgeting and fund flow mechanism, delegation of administrative and financial powers, etc.
- Mindset and the working environment of the functionaries do not encourage innovation especially at the grass roots level.
| Finalize Coordination Mechanisms|| |
To begin with the programs to be brought under ISC are to be listed from all the stakeholders. From this (list) specific areas to be identified for convergence and levels of required integration and coordination to be ascertained. For smooth implementation Coordination committee to be formed and mechanism to be established for ISC with clear roles and responsibilities. There are to be joint meetings for planning, orientation workshops, and development of monitoring mechanism and follow-ups as illustrated in [Figure 2] below. Measures for smooth, effective implementation and problem solving are also to be part of this mechanism.
To devise inbuilt coordination, cooperation and multisectoral perspective in planning, there is need to establish and institutionalize intra as well as multisectoral mechanisms at all levels. The most important step in strengthening multisectoral convergence is to set up a strong communication process having a meaningful framework of intra communication which ensures that the communication is evenly spaced and effective. This framework would specify what and when to communicate and to whom. The framework should be designed in such a manner, which not only lists stakeholders and identifies channels/occasions where communication takes place but also provides predetermined timeline and its frequency for valuable inputs.
| Channels for Strengthening Communication|| |
As state and district health societies are overall responsible for health delivery, these (societies) need to have meetings at regular intervals. Foremost is the joint planning for state annual training calendar like for various activities under RCH program. Regular meetings with the State Information, Education, Communication (IEC) division need to be organized having the involvement of representatives of the respective units/departments for planning media campaigns, advocacy activities. The main agenda should be on prioritizing focus areas, e.g., celebration of health days, and village health and nutrition days (VHNDs). These meetings also provide quarterly interface for Malaria Information System (MIS) for collation of data reports, etc., Moreover, mechanism needs to be established for sharing the annual action plan for each department.
| Establishing Channels of Regular Communication/Interface|| |
Establishing channels for operationalizing and institutionalizing effective intra communication and probably IEC and advocacy could be an effective starting point for this. Strengthening the state and district IEC divisions need to be taken as one of the priorities. As many departments are not directly involved in health delivery, hence mechanism needs to be established for building their capacities and enhancing knowledge through orientation workshops about various programs. Primarily, the stakeholders involved are shown in [Figure 3].
Formulation of annual advocacy plans, media campaign, etc., is to be developed in collaboration with the state IEC division. Common messages are to be developed for all the participating departments and dissemination of health-related information through print media to be given to avoid confusion and incoordination.
| Expected Outcomes of Multisectoral Approach|| |
Measurements of the outcomes from the implementation of the MSA plan would guide in evaluation and necessary course correction. Moreover, some of these (outcomes) are; (a) stakeholders working in partnership for a common goal which would enhance the quality of services, (b) optimal utilization of good quality RCH services by the community especially adolescents and women, (c) easy accessibility of primary and basic quality health care services at the village level, and (d) efforts made to formulate “Integrated Annual Action Plans” for strengthening “Intradepartmental Coordination and Communication,” resulting in a strong foundation for multisectoral convergence at various levels in the state.
| Strengthening Institutional Mechanism for Effective Multisectoral Convergence: An Example|| |
As we have noted earlier that for effective ISC the convergence committees are to be formed at state and district levels and fundamentally they have to standardize the coordination and communication among all the participating stakeholders. Hence, primary tasks of these committees at different levels are as follow:
ISC at community level will lead to improvement in delivery and demand of services. Department of Woman and Child Department (DWCD) and Panchayati Raj institutions (PRIs) are the major stakeholders at this level, and their optimal roles as part of ISC are required to improve the utilization of health services.
Convergence with Department of Woman and Child Department
The anganwadi worker (AWW) and Accredited Social Health Activist (ASHA) who manage weekly immunization day at the village level should also use this platform for orienting village women on various health issues. Multisector meetings at the block level to be regularly convened by Child Development Project Officers (CDPOs) of DWCD. At the Community Health Centre level, monthly meetings to be organized by Medical Officer, which are attended by CDPOs and supervisors to discuss critical health issues of the area. It is proposed that the representative of the Village Health Sanitation and Nutrition Committee (VHSNC) should also participate. Officers of DWCD should be adequately oriented about the functioning of VHNDs, VHSNCs, formulation of village/district health plans under NHM so as to help them to contribute significantly in the making of these plans.
Convergence with Panchayati Raj Institutions
Coordination to be enhanced among village level functionaries such as AWWs/ASHAs, women Panchayat members as well as ANMs for better local planning, implementation and community mobilization. Efforts shall be made to ensure that all members of the Zila Parishad participate in the monthly meeting convened by the Chief Medical Officer of the concerned district. Their participation can go a long way in prioritizing local issues and in the wider dissemination of information and awareness generation among the community and various stakeholders. ASHA should regularly attend the meetings of the Village Health Committees so that the village level concerns of women relating to RCH services, hygiene, sanitation, safe drinking water, etc., are duly addressed at the meetings attended by her. Involvement of the extension workers of the selected line departments in propagating behavior change communication messages on RCH care services.
| Role of Public Health Cadre|| |
Creation of PH cadre is strategic move to meet the major health challenges being faced by the health system, and it would be anchor of establishing systematic ISC incorporating all the principles as discussed above., Soto responds to the current public health challenges and to deliver the functions related to PH the requirement of PH cadre becomes obligatory. PH cadre can ensure multisectoral convergence for robust program planning, implementation, and monitoring. National Knowledge Commission, 2005 set up by Hon. Prime Minister, HLEG 2012 on Universal Health Coverage and the Steering Committee on the 12th 5-year plan, 2012 have recommended development of PH cadre and their empowerment under Public Health Act, while NHP (2017) also highlights the need for having PH cadre and PH Management Cadre.
| Guiding Principles for Public Health Cadre Development|| |
- States are in driving seat and need to lead the process of PH cadre development
- There shall be minimal restructuring and disruption at block, district and state level. However, some new positions have to be created by state and center
- The states shall be encouraged to utilize existing HR positions created by the states as part of their health system and through NHM, PRIs, etc.
- PH cadre development should also focus on multidisciplinary approach by involving veterinary science professionals to address zoonotic diseases, social scientists and health economists for SDH issues, etc.
| Public Health Cadre Development|| |
- Public Health Foundation of India has made progress in establishing PH cadre in different states as per the mandate of GOI and following developments have taken place
- Advocacy meetings with key stakeholders in states (Madhya Pradesh, Kerala, Haryana, Punjab, Arunachal Pradesh, and Bihar) for developing of PH cadre
- Assisted in constitution of technical committees in respective states for PH cadre development
- Facilitated required consultations, workshops, visits to other states (Tamil Nadu, Maharashtra, etc.) to provide orientation to the state officials in collaboration with National Health Systems Resource Centre.
| Applications of Multisectoral Approach: Examples|| |
District health action plans under multisectoral approach
A convergent approach for interventions under the umbrella of the district plan seeks to integrate all the related initiatives at the village, block and district levels, as the indicators of health depend as much on drinking water, nutrition, sanitation, female literacy, women's empowerment as they do on functional health facilities. The District Health Action Plan is seen as the main instrument for planning, multisectoral convergence, implementation, and monitoring of the activities under the NHM. Keeping in mind the regional variations, it is more appropriate that need based planning is done at district level, i.e., prioritizing local needs, and area specific initiatives are taken. Decentralized joint district planning across sectors was initiated under the RCH II and the district plans developed for RCH-II formed an integral part of National Rural Health Mission (NRHM) implementation plans.
Malaria elimination has been involving the players beyond health sector such as nongovernmental organizations (NGOs), Central Reserve Police Force, Border Security Force, and private providers. Private providers are being given trainings and integration of data on malaria endemicity collected by private hospitals with the national MIS. Collaboration has been established with public works department for environmental management, meteorological department for early warning system for outbreaks, agricultural department for safe irrigation and agricultural practices, education sector for promoting awareness on malaria prevention and control, water department for safe water practices and tourism industry for preventing malaria in travelers and cross-border spread of malaria.
| Noncommunicable Disease Prevention and Control|| |
Given that inequities in noncommunicable diseases (NCDs) manifest themselves in the form of differential health consequences, due to varied exposure, social stratification, and differential vulnerability, action is needed from health as well as allied sectors. Aligning the NCD effort with the health and development agenda at all levels will help address these challenges. MSA will need to start at the planning stage and continue to the implementation, evaluation of interventions and enactment of public policies. An efficient multisectoral mechanism is also crucial at the stage of monitoring, evaluating enforcement of policies, and analyzing impact of multisectoral initiatives on reducing NCD burden in the country.
Tobacco control provides a good example for the need and the potential impact of multisectoral action in NCD prevention and control. Effective tobacco control involves not only addressing it at the individual level (preventing use by individuals, helping users to quit) but also leveraging MSAs to address production, trade, taxation, and implementation of tobacco control laws. The implementation of the international tobacco control treaty, Framework Convention on Tobacco Control, requires and obligates the participation of sectors beyond health in achieving its goals. In India, an “Inter-ministerial Task Force for Tobacco Control” exists, under the aegis of the MOHFW that has participants from ministries including: Labor, Commerce, Information and Broadcasting, Agriculture, Ministry of Rural Development, Department of Revenue, Department of Industrial Policy and Promotion, and Food Standards and Safety Authority of India; Drug Controller General of India and civil society members among others. A steering committee that facilitates the enforcement of tobacco advertising ban exists at national, state, and district levels. This committee at the center includes members representing Ministry of Information and Broadcasting, Ministry of Law and Justice, and NGO members from multidisciplinary backgrounds.
Multisectoral project for HIV/AIDS prevention
The Red Ribbon Express project of National AIDS Control Organization presents one successful model of partnership comprising Government (Ministries of Railways, Social Welfare, and AIDS Control Organization) and nongovernmental stakeholders (Rajiv Gandhi Foundation), intergovernmental bodies (UNAIDS and UNICEF), engaging national programs such as NRHM and local governments (Panchayati Raj) to address a communicable disease. The project drew on the strengths of its partners such as the Railways for mobility, Information and Broadcasting for publicity and UNICEF for communication strategy, thus proving cost-effective and resourceful.
Finland's community-based cardiovascular disease prevention project (North Karelia Project)
This comprehensive intervention involved community health education and empowerment, improved health services delivery, prevention efforts in multiple settings (schools and workplaces), media partnership, with greater involvement of civil society and the private sector. Health promoting PH policies too had a critical role in this success through regulating food labeling, tobacco regulations, and shifting agricultural subsidies to encourage low-fat alternatives.
Singapore's Health Promotion Board
Established in 2001, coordinates national health promotion efforts and disease management programs to reduce NCDs, by engaging multiple sectors. It adopts a settings-based approach for health promotion activities to prevent NCDs, complemented by screening and treatment of those with clinical diseases. Public education through media, food labeling, and tobacco control policies has facilitated adoption and practice of healthy choices by communities.
Therefore as shown in [Table 1], for smooth implementation of ISC, clear cut roles and responsibilities at State, District and Block levels to be defined and performance to be measured against these defined tasks at each level.
|Table 1: Roles and Responsibilities at different levels for smooth implementation of ISC|
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| Ideal Situation for Multisectoral Approach|| |
- Opportunities and mechanisms for routine multisectoral collaboration
- Sufficient resources and time allocated for effective multisectoral collaboration
- Open, inclusive, and informed discussion among key stakeholders
- A policy process and policies shaped and influenced by multisectoral inputs
- The monitoring and assessment of collaborative partnerships for learning and improvement
- Evidence generated and shared on the cross-sectoral benefits of achieving the stated health goal through a multisectoral response.
| Conclusion|| |
Promotion of MSA within the health system and with other ministries is seen as an important measure for effective implementation. Strengthening communication is one of the key requisites for ensuring multisectoral coordination., MSA is a means of improving effectiveness and efficiency of PH programs. PH cadre can ensure multisectoral convergence for robust program planning, implementation, and monitoring.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]