1. Leveraging inter-sectoral action to address the social determinants of health: view from the health system Lucy Gilson University of Cape Town; London School of Hygiene & Tropical Medicine

2. Acknowledgement Drawing on work conducted for the WHO Commission on the Social Determinants of Health, including the health systems knowledge network, by the Public Health Agency of Canada (PHAC 2007, 2008)

3. Inter-sectoral action for health Actions taken by sectors outside the health sector, possibly, but not necessarily, in collaboration with the health sector on health or health equity outcomes or on the determinants of health or health equity (PHAC 2008: 2)

4. Varying goals To improve health equity by reducing the gap in health status between specified groups To enhance the health of the population (with no specific concern for equity) To address a key determinant of health (but without focussing on health gains) To support health system re-design

5. Such strategies may focus on a specific population (e.g. indigenous peoples) or health issue (e.g. anti-tobacco strategy) working within a defined, local area (e.g. UK Health Action Zones, Healthy Cities projects) working incrementally over long time scales (e.g. the Water, Sanitation and Health Protection of the Human Environment initiative) broad policy frameworks (e.g. MDGs)

6. A continuum of strategies Sectors working separately but sharing information or coordinating activities Actors contributing meaningful resources towards shared outcomes, with joint planning

7. Influencing factors

8. EnablersConstrainers Ideological & political context Supportive societal values; broad government support; Emergency situations Social divisions; State fragility; Low political priority. Economic environment Budget expansion; Budget cuts as stimulant Poor economic growth; Budget cuts Electoral cycleElections & new political leadership Short-term political horizons Government structures & decision-making processes New money Dedicated budgets Government silos & funding structures National/local disconnect Institutional structures Legislative & policy foundations, requirements Sustained only by individuals CapacitySkills & commitmentStaff turnover Weak skills

9. What leadership role for the MOH?

10. The role of health sector is no longer straightforward. It must be able to shift and adapt. It must know when to lead, when to follow and what type of input to seek. It must also be vigilant in ensuring that the health aspects of complex files led by other sectors are identified and addressed. It must be sensitive to timing, able to distinguish among short-, medium- and long-term gains, and prepared to make decisions on appropriate entry points and strategies (PHAC 2007)

11. Scenario 1: dealing with an issue on which health sector has greatest knowledge e.g. improving health care access Scenario 2: MOH has knowledge about relevant action but does not control implementation arena e.g. health promoting schools Scenario 3: MOH neither has greatest knowledge nor implementing power as action addressing a social determinant (education, poverty); health sector a partner not leader

12. Ministries of Health can leverage IAH better by: –Making the case for IAH –Taking the strategic needs of other sectors into account, clarifying the role of the MOH –Setting explicit goals and objectives –Building trust-based teams with wide range of skills –Institutionalising IAH

13. Making the case Evidence and media reporting to highlight health inequities, health needs of specific population group Need framed in ways other sectors can understand & relate to (emphasise social, economic & cultural aspects) Building on need to use resources more efficiently Political champions - local or national political leaders High-level political support - especially from Treasury Taking advantage of political transitions Building on international leadership Recognising problems of current approaches Holding shared gatherings to build consensus

14. Institutionalising IAH Specify nature of collaboration & roles of all partners e.g. develop MoUs Developing permanent structures rather than project based initiatives Dedicated funding programme Central guidance & support for local staff (training, guidance, sharing experience), but local level flexibility Performance incentives Mandatory requirements e.g. for health impact assessments Citizens forums to maintain pressure

15. Successful intersectoral action requires the sharing of power (PHAC 2008, p.20)

16. Remaining questions (PHAC, 2008) How strengthen national-regional-local integration? What impact from framing goal as about health equity vs. non-health goal? How define & evaluate success? How can health sector build capacity to collaborate effectively? How best to engage other sectors? Are time-bound targets useful? What are key issues for sustainability?