Intersectoral policy priorities for health

Many aspects of population health can be addressed solely by services delivered through the health sector. These services include health promotion and prevention efforts as well as treatment and rehabilitation for specific diseases or injuries. At the same time, policies initiated by or in collaboration with other sectors, such as agriculture, energy, and transportation, can also reduce the incidence of disease and injury, often to great effect. These policies can make use of several types of instruments, including fiscal measures (taxes, subsidies, and transfer payments); laws and regulations; changes in the built environment (roads, parks, and buildings); and information, education, and communication campaigns (see chapter 1 of this volume, Jamison and others 2018). In addition, a range of non–health sector social services can mitigate the consequences of ill health and provide financial protection. These intersectoral policies that promote or protect health, when implemented as part of a coherent plan, can constitute a whole-of-government approach to health (UN 2012).Ideally, a whole-of-government approach to health would involve the systematic integration of health considerations into the policy processes of all ministries. This collaborative approach is often termed Health in All Policies (Khayatzadeh-Mahani and others 2016). Some governments have achieved such collaboration by employing ministerial commissions or other mechanisms comprising top-level policy makers to enable health-related decisions to be made across government sectors (Buss and others 2016). The goal is to create benefits across sectors by taking actions to support population health and beyond that, to ensure that even “nonhealth” policy decisions and implementation have beneficial, or at least neutral, effects on determinants of health. Intersectoral involvement increases the arsenal of available tools to improve health, helps ensure that government policies are not at cross-purposes to each other, and can generate sizable revenue (as in the case of tobacco and alcohol taxes).Many countries do not practice a Health in All Policies approach, and doing so is especially challenging when there are extreme resource constraints, low capacity, and weak governance and communication structures (Khayatzadeh-Mahani and others 2016), as in many low- and middle-income countries (LMICs). As an alternative in these settings, a ministry of health could engage other sectors opportunistically and strategically on specific issues that are likely to produce quick successes and have substantial health effects (WHO 2011a). Thus, a concrete menu of policy options that are highly effective, feasible, and relevant in low-resource environments is needed. This need is particularly relevant in light of the ambitious targets specified in the United Nations Sustainable Development Goals (SDGs) for 2030 (UN 2015).The Disease Control Priorities series has consistently stressed the importance of intersectoral action for health and the feasibility of intersectoral action in LMICs. Disease Control Priorities in Developing Countries, second edition (DCP2) (Jamison and others 2006), included chapters that emphasized intersectoral policies for specific diseases, injuries, and risk factors, and it also included a chapter devoted to fiscal policy (Nugent and Knaul 2006). Disease Control Priorities, third edition (DCP3), has reinforced many of these messages—usually with newer and stronger evidence—and has also explored some emerging topics and new paradigms, particularly for control of noncommunicable disease risk factors. Volume 7 of DCP3 is especially noteworthy in this respect: it provides a list of 111 policy recommendations for prevention of injuries and reduction of environmental and occupational hazards, 109 of which are almost entirely outside the purview of health ministers to implement (Mock and others 2017).Despite the political barriers to developing an intersectoral agenda for health, this chapter contends that not only is intersectoral action a good idea for health—it is a must. Much of the reduction in health loss globally over the past few decades can be attributed to reductions in risk factors such as tobacco consumption and unsafe water that have been implemented almost exclusively by actors outside the health sector (Hutton and Chase 2017; Jha and others 2015). An environment that increases health risks at early stages of industrial and urban growth often, although not always, gives way to a cleaner natural environment at higher levels of per capita income. Yet these risks can be associated with dramatic health losses along the way (Mock and others 2017). Furthermore, the health risks produced by advanced industrialization—such as unhealthy diet and physical inactivity—require policy interventions across multiple sectors if they are not to worsen substantially with economic development.This chapter is based on a close look at the intersectoral policies recommended across the DCP3 volumes, and it proposes 29 concrete early steps that countries with highly constrained resources can take to address the major risks that can be modified. The chapter also touches on broader social policies that address the consequences of ill health and stresses that the need for such policies will increasingly place demands on public finance. This chapter can be viewed as a complement to chapter 3 of this volume (Watkins and others 2018) concerning health sector interventions in the context of universal health coverage. It also provides illustrative examples of successful health risk reduction through intersectoral policy and discusses various aspects of policy implementation. By synthesizing non–health sector policies separately and in greater depth in this chapter, DCP3 seeks to reinforce the importance of these policy instruments and provide a template for action for ministers of health when engaging other sectors and heads of state.