The need for inter-sectoral action and support is central to the “Investment in Health” approach.. Although the concept of inter-sectoral working to achieve health gain is not difficult to understand or support, in practice, this way of working is counter-intuitive and counter-cultural.. Moreover, inter-sectoral working can be difficult for politicians to support where they are held to account for the successful operation of a single policy sector.
In many parts of Europe, such as the UK, inter-sectoral working is difficult at regional level because a large amount of policy is driven from central government. The Provinces of Trento and Bolzano are fortunate in being relatively autonomous. Theoretically, they have considerable potential to control the way that investment is handled across the public sector.
Some of the main lessons from the “Investment in Health” project about how to make inter-sectoral action a reality were as follows:
- The Health Department took primary responsibility for the “Investment in Health” demonstration project. Then there was clear overall responsibility for the project. But the dominance of the health sector at the outset meant it was more difficult to engage the input of other sectors. The WPT had, however spent some time gaining the commitment of politicians and opinion leaders within the Provinces before the project actually started. One argument is that the health care sector needs to get its own act together before approaching negotiations with other policy sectors and then proceeding to external integration with other groups. An alternative view is that the level of mistrust between organisations and government departments can be minimised if those sectors are involved early on to ensure that they are committed to the approach and overall objectives.
- A crucial factor is securing commitment to the “Investment in Health” project was the interest of a respected external body – the Fondazione Incontri di Madruzzo. The Foundation is not only a well respected, it also has a wealth of experience in enabling and supporting cultural initiatives that spread across the remit of more than one organisation or sector. As well as the local presence and mediating role of the Foundation, the brought input of the WHO gave kudos to the project which was important in persuading politicians that the initiative was worth their support.
- Inter-sectoral working requires a different mind set to the way the most managers and civil servant operate. Experience elsewhere has shown that bureaucratic approaches will not work: flexibility and a willingness to try new things are essential.. Clear objectives and expectations can help allay some of the natural suspicion but these do not really address the processes that are required. Inter-sectoral working requires a keen understanding of the micro-politics of the way that organisations work and effective ways of using power and influence to negotiate desired objectives. These sorts of skills are not developed overnight. They need to be learned from experience and practice.
- When working across policy sectors and across international boundaries the need for clear definitions of terms becomes very important. A glossary of terms can help.
- The essence of effective inter-agency working is having enough political power behind and support for a particular initiative to make it happen. There will be also many technical difficulties to solve once that commitment has been achieved - such as finding mechanism that allow accountability for resource use but which pool the budgets of one or more sectors.
- The larger the number of sectors and organisations involved in a particular initiative, the more complex the processes for communication are likely to be. Although use of new information technology can help, these are not substitute for having a clear set of priorities about who needs to be informed or consulted about what and how they will be contacted.
..At a more general level it was recognised that the most important things to be done in moving from a demonstration project to local implementation were about getting support and commitment to the ideas. The following steps were identified as useful means of doing this.
- Nominating a commission of experts to work up the actions into a detailed projects
- Developing a social marketing plan that targets different sectors of the population.
- Setting up groups of stakeholders to explore each proposal in detail and evaluate their feasibility.
- Facilitating consensus and political support across policy sectors.ß Identifying opportunities for public and private sector collaboration in aspects of implementation.
- Organising events to bring together different agencies and community groups.
- Establishing a group of opinion leaders, institutions and organisations.
- Using the influence of a third party such as WHO or the Foundation Incontri di Madruzzo to signal the importance of the initiative.
- Identifying means of communications which are relevant and sensitive to different audiences.
- Using media to increase awareness of the work and the concept of “Investment in Health”.
- Mobilizing social networks through cultural events.
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