1. Coordinating Multiple Programs and Services: Exploring Coherence and Fit School Health 2008 Nancy Edwards, RN, PhD School of Nursing and Department of Epidemiology and Community Medicine

2. Why the Shift to Comprehensive School Health Programs? Comprehensive programs – more than a basket of interventions Reflects a deeper understanding of underlying determinants across the life course “Comprehensive pediculosis screening programs for elementary schools.”

3. WHO Commission on Social Determinants of Health Interim Statement (2007) “Action is needed on the determinants of health – from structural conditions of society to the more immediate influences, at all levels from global to local, across government and inclusive of all stakeholders from civil society and the private sector. Key to multilevel action is coherence.”

4. Public health core competencies http://www.phac-aspc.gc.ca/ccph-cesp/stmts-enon- eng.html#4 Assess, analyze and apply information Policy and program planning, implementation and evaluation Partnerships, collaboration and advocacy Communication Leadership

5. Poverty in the midst of wealth

7. Synergistic or antagonistic with what? Synergies between interventions and context may be most critical.

8. Constraints on Achieving Coherence in Comprehensive Programs Sector-specific planning Focus on proximal rather than distal influences Focus on familiar rather than unfamiliar determinants Dynamic changes – leadership, political processes Growing inequalities and inequities Disengaged families and communities

10. People’s Republic of China Yunnan Maternal & Child Health Project, Yunnan Province, China Beijing

11. Yunnan Maternal and Child Health Project Purpose: Purpose: To improve the quality of village life and promote the development of productivity and social prosperity in poor ethnic minority counties in Yunnan Province Participatory training for grassroots workers Essential MCH equipment Strengthen MCH referral mechanisms Participatory monitoring and evaluation

13. Co-constructing the language to describe core project elements Sharing experience Modeling different forms of inquiry Surfacing underlying assumptions

14. Threats to Project Sustainability (Edwards & Roelofs, CJPH, 2006) Uneven support for the training innovation across system levels Work unit leaders expressed doubt about the utility and appropriateness of participatory approaches for village health workers Supervisory approaches mirrored the authoritative and didactic approaches to training that were standard practice Significant national reforms increased work demands and threatened job security Multi-level support and fit with cultural context

15. Developing Management Systems with Cross-Cultural Fit (Edwards & Roelofs, Intl J Health Plann Mgmt, 2006) System dimensions –Administrative and financial systems –Governance structures –Communication systems –Monitoring and reporting systems –Human resource infrastructure Areas of assessment –Cultural context –Capacity –Rapid systems change –Accountability

16. Cross-cultural fit of management systems - examples Where do the negotiation and expression of dissenting views happen: during public meetings, in private meetings or behind closed doors? How is approval for a change in policies communicated between different levels of the system? How is the balance between responsibility and accountability shared between managers and working level staff?

17. Yunnan, China – Lessons Learned Authentic participatory approaches must be infused through all levels of the work including management structures, decision-making processes & evaluation approaches A deep mutual understanding of an intervention must be co-created by partners Never assume the intervention has “taken hold”

18. Coherence and Fit What is the relevance to School Health? Project fit must be continuously co-created by partners within a dynamic context Fit can be examined in more depth when underlying assumptions are surfaced Building project coherence requires attention to both vertical and horizontal alignments Governance and evaluation systems for comprehensive programs need to bridge sectors and levels