An Evolving Approach To Collaborations Among Health And Other Sectors
Much evidence exists on the potential for prevention and health promotion to decrease the burden of chronic diseases. The Institute of Medicine (IOM), for example, has issued many reports with recommendations to use population-based and individual prevention programs and policy and legal interventions to improve diets, increase physical activity, and stop tobacco use.
These reports also note that achieving progress in health promotion will require the engagement of other non-health sectors. This isn’t breaking news—terms like “multisectoral” or “health in all policies” prevail in public health dialogue. Yet the question remains – if it is so well accepted that the health sector alone cannot improve health, why don’t multisectoral programs and policies happen more often and more successfully?
Redrawing What “Multisector” Looks Like
When the public health sector talks about engaging multiple sectors to improve health, we often envision something like a Venn diagram of neatly overlapping spheres of influence with health in the center.
But reality looks more like this:
Each sector itself is not a well-defined circle, and health isn’t conveniently at the center relative to other sectors. In reality, sectors overlap in complicated ways, and there really is no center. There is actually much more interconnectedness — the blue area of overlap — than a simplified Venn diagram captures. This means that there is a lot of room for sectors to interfere with each other’s goals if we aren’t careful, but it also means that there are more opportunities for mutually beneficial collaboration than we might otherwise have envisioned.
When any sector puts themselves at the center, harm can result. For example, health has often been sacrificed when the goals of other sectors take precedence. Take the following examples: Economic drivers support a tobacco industry that has dire consequences for health. Government investments in transportation focus disproportionately on roads and neglect efforts to promote active daily mobility. Physical education classes are cut in education reforms. Government incentives and regulations in agriculture lead to food production that fails to align with recommendations for healthy food intake. Even in sectors within health, resources are often directed away from prevention and into clinical health systems and biomedical interventions.
Conversely, there has been harm to other sectors when we have put health goals at the center without carefully considering their impacts across other domains: Reduction of trans fats in foods led to increased use of unsustainably produced palm oil, contributing to environmental harm and heart disease. Consumers eating more fish for its health benefits contributes to overfishing and long-term economic damage in some communities. A declining tobacco industry affects the household and local economies of tobacco farmers. A recent Minnesota Department of Health report concluded that some of its own health practices reinforce structural racism by not accounting for how they benefit one population more than another.
Perhaps if we embrace the “messiness” of multisectoral relationships we can turn this complexity into an asset rather than a hindrance. We then may be in a better position to not only reduce the inadvertent harm that sectors can cause one another but also to discover new opportunities in all the “blue space” to design and support programs that benefit multiple sectors and multiple aspects of individual and community life. Some people and programs are already doing this. Here are a few examples:
- Health and productivity. Prevention and health promotion interventions in the workplace have the potential to improve not only health but also morale, productivity, and a business’s bottom line. This is not limited to the private sector. HealthLead, for example, has developed standards of wellness for college and university campuses. In the defense sector, addressing obesity, tobacco use, and depression is a priority because of their effects on force preparedness and national security.
- Agriculture, schools, and nutrition. The Healthy, Hunger-Free Kids Act authorizes the US Department of Agriculture to use federal money to ensure that children have healthy food and environments in school.
- Schools and adolescent health. In the Oakland Unified School District in California, Medicaid funds and school bonds were used together to build adolescent health clinics in schools and increase access to preventive and behavioral health care in low-income communities. In turn, the presence of clinics in schools may contribute to decreased high school drop-out rates.
- Education, health workforce needs, family support, and employment. The Community Action Project of Tulsa County is piloting a two-generation program in which parents take classes to earn health care credentials while their children attend Head Start. Employment opportunities are facilitated by relationships between the early childhood education program and local health care providers.
- Health, transportation, and urban economic development. Urban infrastructure improvements, such as the Atlanta Beltline, have effects on, for example, property values, walkability, and recreation. These approaches are truly multisectoral if they mitigate effects on low-income residents, which were explored, for example, in a health impact assessment of light rail development policy in St. Paul, Minnesota.
We are currently only scratching the surface of potential innovative multisectoral opportunities that could advance prevention goals. By genuinely engaging other sectors to develop strategies that help each other, we can follow the same “shared value creation” approach as the private sector.
How Can We Do This?
The Association of State and Territorial Health Officials suggests building ongoing relationships with other sectors to identify common goals and achieve them using shared expertise and resources. Two tactics stand out that we in the public health sector can use to build such relationships and to more successfully promote health in tandem with priorities in other sectors. First, we can listen more to better understand other sectors and our complex connections to them. Second, we can do more to show the ways in which health benefits from and brings value to other sectors.
Listen: What Do Other Sectors Want And Need?
Those committed to promoting health often assume everyone should highly prioritize health. But, while we work to persuade other sectors to adopt changes just because they will improve health, we could also take time to listen to what they primarily want or need to accomplish. To better understand how their priorities connect to health and to find potential new opportunities to collaborate that meet their goals as well as ours, we should:
Host listening sessions. Continue to bring together people from transportation, agriculture, housing, city planning, education, social work, etc. – but ask them to tell us about their values and approaches, and what the health sector might contribute to their work.
Go where the other sectors are. Participate in listservs, meetings, and activities in other sectors and settings. Go beyond our comfort zones and areas of ready agreement. Innovation often happens on the boundaries of disciplines, not within them, and we need to make ourselves available for unexpected connections.
Elicit community perspectives to better understand how sectors connect. Individuals and communities do not experience the effects of interventions in sectoral silos and they have the most inherently integrated view of how health, food availability, education, housing, employment, and transportation interrelate to affect their daily lives. Use community councils, public sessions, research, and other methods to identify interconnected needs.
Find the people who can change the future. Identify and engage existing leaders in other sectors who are interested in health. Appreciate and draw on the expertise of non-health people who have health-related insights.
Show: What Value Do Health And Other Sectors Bring To Each Other?
To promote health through collaborative approaches, we need to ensure that policies and interventions provide benefit and avoid harm across domains. To better monitor and demonstrate mutual value, we can:
Expand shared measurement frameworks to include health. Too often health has been excluded or only marginally included in shared frameworks intended to track core societal and economic values, such as the World Bank’s approach to impact assessment or the Dow Jones Sustainability Index. The United Nations Global Compact and the Global Reporting Initiative, for example, are intended to ensure that advances in commerce, technology, and finance advance benefit economies and societies. They include considerations specific to labor, human rights, and the environment, but exclude health.
Incorporating health measures into shared reporting structures will be critical to incentivize all sectors to recognize health as a strategic imperative, and it is also an opportunity for those sectors to see the value of aligning their actions with promoting health. Health-inclusive shared measurement approaches have shown these benefits (as illustrated in these papers by Bhatia and Wernham, Frangos et al., and Tahzib et al.). Transportation reform in Massachusetts, for example, included shared approaches to assessing transportation, environmental, health, and socioeconomic impacts.
Expand what we measure as outcomes of health interventions. Just as other sectors profoundly affect health, health is an upstream driver contributing to other sectoral interests, such as improving educational achievement or reducing poverty by increasing employment stability and limiting family health expenditures. A broad view of relevant measurements for health is not new – for example, America’s Health Rankings incorporate social, economic, and physical environment measures — but this principle is applied primarily to track these factors as determinants of health. If these factors can also be considered and measured as effects of health policies and interventions, it may be easier to convince partners, policy makers, and funders that health approaches can help them to reach their non-health aims.
For example, an active living campaign run by the public health department that promotes biking can work with the transportation department to measure the campaign’s effects on traffic congestion and road safety. A project to deploy community health workers to homes to monitor and support the health of young children in low-income neighborhoods can work with the education department to measure the effects on school attendance and academic outcomes such as grade-level reading. If we prove that health interventions have value by contributing to outcomes that others care about, we will make a stronger case for collaboration, support, and investment.
To advance how we engage other sectors to help improve health, we can measurably demonstrate shared value and uncover new possibilities for mutual benefit. Let’s push for better measurement of how other sectors impact health, and at the same time show the value that health-promoting interventions bring to other sectors. And as we converse with other sectors, let’s continue to ask for their help in achieving health aims, and more actively ask them what they need and how the health sector can help them achieve it.