Health promotion, partnership and intersectoral action

The practical and scholarly field of health promotion has firmly established itself as a discrete area of development since the first calls for broader health developments were voiced in the early 1980 s. A healthy debate continues over whether ‘health promotion’ is or should be a dedicated (and accredited) field of social development in (private and public) service delivery, and whether it is an academic discipline on its own, or a cross-cutting scientific endeavor. In different countries and contexts, the debate veers in different directions. Our journal—together with sister journals that highlight other important dimensions of the field—has consistently supported the conceptual development of health promotion. Our mission is not just to publish elegant research, but to push boundaries in thinking about determinants of health, systems and policies of health development, the depth and width of relevant settings for health, the development and celebration of cutting-edge theory and methodology and the inclusion of the broadest possible range of stakeholders in recognition of all qualities of health–not just disease and sickness. Health Promotion International, for those reasons, is not just a vehicle for the publication of excellent articles. We hope to advance the field, together with our partners (the World Health Organization, the International Union for Health Promotion and Education, Oxford University Press, the Victorian Health Promotion Foundation, and the institutions that allow our editorial team to spend time on an otherwise mostly volunteer effort). Recently, we realized that we should make a more express effort to reflect on and review our past accomplishments, so their evidence base is more clearly documented. As a first step, we now offer ‘virtual theme’ issues in which we present our editors’ choice of key papers published during our 32-year history. The readership and our partners are welcome and encouraged to suggest areas of interest for future virtual issues. Our first collection takes up the topic of partnership and intersectoral action for health. Health promotion, since its inception, has recognized the impact that sectors other than the health sector have on the experience of human health (WHO, 1978, 1986). Evidence has shown that education, income, social position and many other economic, political and social factors either support, or inhibit, people’s access to and experience of health, health equity and wellbeing (Wilkinson and Marmot, 2005). The imperative to address social determinants has been met with a key strategy in health promotion—intersectoral action. By partnering with sectors outside the health sector, we are better able to address the underlying causes of the conditions which create health and, especially, health disparities (Public Health Agency of Canada and World Health Organization, 2008). Intersectoral action involves partnerships across the spectrum of health promotion initiatives locally, regionally and nationally (Jackson et al., 2006). Such collaboration is not easy to establish or continue, and a substantial body of research has been published on partnerships in health promotion, policy and practice. In this virtual collection, we highlight pivotal work published in Health Promotion International on partnership and intersectoral action. In this introduction, I will highlight the major contributions of these papers as they relate to building the case for such work, informing policy making, describing practice in a variety of health settings and introducing theoretical and methodological advances to the field. I will conclude by reflecting on the gaps that remain and challenges that will inform ongoing scholarship and change in this area. In 1998, Pam Gillies (Gillies, 1998) reviewed the evidence for the effectiveness of health promotion partnerships and alliances using two approaches. Gillies describes how she conducted a review of literature published in the period from 1986–1997, and engaged a network of health promotion experts who helped identify best practices. From these efforts, she concludes that intersectoral collaborations ‘do work’ in impacting change both on the determinants of health as well as on more individually focused behaviorial change initiatives. Gillies also notes that the more local community partners are engaged in agenda setting and implementation, the greater the impact of partnership. Given the importance of this engagement, Gillies advocates for the creation and maintenance of durable structures such as community committees and councils. She argues that such structures provide venues which enable sharing power, decision-making, responsibility and authority, ensuring program relevance and providing a forum for communication and disagreement. Gillies also raises the issue of the inadequacy of traditional indicators for measuring the success of intersectoral collaboration. She argues that individual level indicators are not sufficient for measuring such work, as they fail to recognize the impact on families and communities. She calls for broader social indicators to be incorporated, specifically, social capital as a measure. At the time of this review, Gillies paper has been cited 478 times–a nod to how influential her findings have been in shaping our thinking on inter-sectoral action and how we measure its impact. In 2000, Marilyn Wise and Louise Signal (Wise and Signal, 2000) wrote about the state of health promotion in Australia and New Zealand, describing diverse initiatives on gun control, tobacco control and nutrition. They highlight effective professional networks mobilizing diverse actors working in health promotion, public health and indigenous health. They note less collaboration between health promotion and healthcare services. An important distinction they highlight is the different nature of short-term partnerships based around specific projects (which disband once goals are met), and ongoing structures that work over many years and across many individual initiatives. They highlight the need for shared vision and the problems that arise when the overlap between partners’ individual objectives is small. In 2006, Suzanne Jackson and her colleagues (Jackson et al., 2006) conducted a review of reviews and used a variety of case examples to explore the impact of various Ottawa Charter strategies in practice. Their findings reiterate the centrality of intersectoral collaboration and inter-organizational partnership for all health promotion activities at every level of action from individual behavior to supportive environments, community action and healthy public policy. They found intersectoral partnerships to be crucial for community-engaged decision making and planning, creating health settings, galvanizing political commitment, resources and infrastructure, and ensuring the relevance of health promotion initiatives for the socio-cultural context. These articles help firmly establish the relevance of intersectoral action as a strategy for addressing social determinants of health. In 2015, Delany and colleagues (Delany et al., 2016) examined intersectoral action as manifest in a Health in All Policies (HiAP) in South Australia. Using data collected from qualitative interviews, two workshops and survey responses, they identify several inter-related core features for implementing HiAP that lead to improved effectiveness. They found that having a dedicated staff and sufficient resources are crucial for an HiAP approach to be feasible. A central mandate from central government bodies helps facilitate effective implementation and engender commitment from diverse departments. Clearly defined timelines and specific milestones help mitigate frustration with time-consuming collaborative processes. They also highlight a potential threat to HiAP implementation–the siloed nature of government departments. They recommend envisioning shared societal goals rather than simply planning around existing department-level objectives. Also examining policy making in Australia, Fisher and colleagues (Fisher et al., 2017) analysed policy documents to understand the health sector’s stewardship role in engaging other sectors in intersectoral action to address SDH and health inequity. Applying an a priori coding frame to 266 policy documents of the national Australian government and eight state/territory governments, they report that the majority of intersectoral action led by the health sector aims at extending individual biomedical and/or behavioral approaches into other sectors. They note a few examples of intersectoral policies that aim to address structural determinants of health inequity, the majority manifesting as settings-approaches, which tend to be limited in impact to proximal circumstances. The one policy they identify as truly addressing the underlying socio-economic determinants is the national ‘Closing the Gap’ policies aimed at reducing inequity for Aboriginal and Torres Strait Islander people. They also note that engagement between the health sector and the sectors that truly impact systemic socioeconomic inequalities is very limited. Looking at municipal level initiatives, Peters and colleagues (Peters et al., 2016) conducted a case study examining 34 municipal projects of the Dutch Gezonde Slagkracht Programme between the years of 2009–2015. They categorize these initiatives on a continuum with intersectoral action (with less policy integration) at one end, healthy public policy (with slightly more) in the middle and Health in All Polices (with the most integration) at the other end. The initiatives could work to eliminate obesity, alcohol and drug misuse, smoking or a combination of these. They examined project application forms and conducted interviews with project leaders. They describe a mix of approaches in their data but found the predominant mode suggested for addressing obesity is intersectoral action. There is more integration in addressing alcohol and drugs (HPP approaches). The initiatives aimed at addressing all the themes were the most integrative and the only one qualifying as HiAP. As broader goals were defined, more integration was apparent, and more partners and sectors were involved. They suggest that if a policy problem could benefit from greater policy integration, it is wise to start from the SDH (epidemiological reality) and systematically transform that into policy (policy reality), then set broad policy goals while inviting other sectors to participate. Also examining municipalities, Holt and colleagues (Holt et al., 2017) conducted 49 semi-structured interviews, informal interviews and collected field notes about efforts to enact intersectoral policy-making in 10 municipalities in Denmark. They found that the key strategy for consensus-building for these partnerships is to position health as a means of achieving non-health sector agendas. The authors found this approach often results in small-scale initiatives such as promoting nutrition and physical activity in a school setting. Meanwhile, ambitious programs to tackle more fundamental structural determinants of health are neglected. The authors note that this might be worse than no intersectoral action at all, since it could corrupt and weaken more effective action on the SDH. These articles introduce important initiatives, approaches, opportunities and challenges for intersectoral action in policy making. The next section explores how intersectoral action is enacted in health promotion practice in a variety of international settings. While there is little research on full-scale intersectoral collaboration in many Southern contexts, in 2009 Mary Manandhar and her colleagues from Zambia and Ireland (Manandhar et al., 2009) combined policy analysis, program review and qualitative research to examine the socio-cultural determinants of maternal survival in Zambia. As part of the project they convened inter-sectoral stakeholders from central (Lusaka) and provincial (Kasama) levels to engage in discussion and debate about the issue of maternal survival using the qualitative research project as the point of entry to the conversation. The meetings included government actors, non-governmental organizations, the indigenous health system, academia, clinical provider associations, media, advocacy and human rights organizations. They found, at the provincial level, that diverse people welcome the opportunity to discuss issues and debate solutions. The process identified needs for creating linkages between state actors and non-governmental organizations, communities and advocacy groups and to scale up efforts to serve isolated rural communities. The authors encountered significantly more challenges facilitating discussions at the central level. They attribute this to turnover in staff, competing priorities and the over-taxed health system targeting disease-focused interventions over efforts to address underlying determinants. The authors also note that Zambia does not have a strong tradition of such collaboration and is often compelled to focus on donor-driven vertical programs which have little interest in such efforts. The authors conclude by saying that relationship building is very important in intersectoral initiatives and that the investment of time and funding for developing connections should not be underestimated. Examining Healthy Cities initiatives in the UK and South Africa, Stern and Green (Stern and Green, 2005) endeavored to understand how partners work within two fundamental tensions of intersectoral partnerships: the inherent conflict in ‘top down’ initiatives which advocate ‘bottom up’ action, and the limitations of the impact of such partnerships compared to the outcomes touted by proponents. The authors found that partners modify their expectations to the realities of the actual partnership by limiting their input to the narrow agenda of ‘boundary issues’ that do not threaten the agenda of the authorities. They found that these partners are content to think of themselves as ‘boundary people’ and that working on relationships to get a ‘foot in the door’ with the people in power (for community partners) and with community leaders (for statutory sector authorities) is still desirable, even if it is not as transformative as promised. Also examining Healthy Cities, de Leeuw and colleagues (de Leeuw et al., 2015) examined the WHO European network of Healthy Cities for evidence of the alignment of a governance for health approach and actual local commitments. Their findings indicate that Healthy Cities with an emphasis on governance show increased participation, policy making and intersectoral action. The longer cities are a part of the European network, the more likely it is they will establish an integrated and accountable approach to policy development that embraces the principles and values of Healthy Cities (and other settings approaches)–in short, that they understand and implement modern governance. The authors acknowledge the benefit of WHO advocating for the governance agenda but note that no data are available to compare a select (even elite) group of WHO Healthy Cities with other, non-networked urban environments. Looking at intersectoral collaboration for the purposes of food and nutrition research, Dixon, Sindall and Banwell (Dixon et al., 2004) examined cases of government, scientific and industry partnerships in Australia. Their results warn of potential for health promotion intentions to be subsumed for sector-specific benefits in such partnerships. They identify a few key motivations that can overpower health goals: the priority of the commercial interests to establish health claims for their products, the need for scientists to raise money for research in the face of limited public funding and governments mandates to provide services through public-private partnerships. Their findings led them to question the independence of dietary advice being promoted from these collaborations. These papers illuminate practical experiences and help inform our understanding of partnerships for inter-sectoral action on the ground. The next section describes papers that advance theory and methodology. 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