Multisectoral Action Research Articles

A review on Noncommunicable Diseases (NCDs) burden, its socio-economic impact and the strategies for prevention and control of NCDs in India.

Noncommunicable diseases (NCDs) have become a major public health problem in India accounting for 62% of the total burden of foregone DALYs and 53% of total deaths. Out-of-pocket expenditure associated with the acute and long-term effects of NCDs is high resulting in catastrophic health expenditure for the households. A large national survey in India found that spending on NCDs accounted for 5.17% of household expenditure. According to a macroeconomic analysis, it is estimated that each 10% increase in NCDs is associated with a 0.5% lower rate of annual economic growth. The income loss due to hypertension is the highest, followed by diabetes and cardiovascular diseases. The macroeconomic impact of NCDs is profound as they cause loss of productivity and decrease in gross domestic product. Since the health sector alone cannot deal with the "chronic emergency" of NCDs, a multisectoral action addressing the social determinants and strengthening of health systems for universal coverage to population and individual services is required.

Integrating economics into the rationale for multisectoral action on obesity.

ABSTRACTObesity is a compelling example of the challenges of championing and mobilizing a response that involves the whole of government and all of society. This paper discusses the need for economic rationales to strengthen the case for government intervention on obesity, with a view to better engaging the expertise and resources of nonhealth sectors. The paper also briefly reviews economic theory and evidence that could support an integrated multisectoral rationale for action, noting opportunities to expand the integration of economic evidence in the Americas.

Shedding light on governance for Roma health inequities

ABSTRACTThe health inequities suffered by the Roma population in Europe represent an alarming and unacceptable source of injustice. As the main ethnic minority in Europe, the gap between the health conditions of the Roma and the rest of the population poses a challenge to human rights and public health. Many political efforts have been deployed in Europe to tackle these inequities. However, they have fallen short, even causing paradoxical consequences. In this paper, we argue that previous political efforts have failed because they were developed from a neoliberal perspective, which perceives Roma health inequities as isolated ethnic problems for which there is no political accountability. Hence, there is a need for transformative political change that results in the protection of rights and self-governance to address health inequities experienced by Roma people. We propose a framework of health governance guided by the following principles: (a) effective involvement of multiple stakeholders by building collaborative capacity; (b) infusion of health perspectives in all policies and multisectoral actions; (c) transparent monitoring and evaluation; (d) role redefinition of policy promoters; (e) prevention of institutional discrimination; and (f) assuring cultural competence among policy promoters.

Hidden hunger in South Asia: a review of recent trends and persistent challenges.

'Hidden hunger' is a term used to describe human deficiencies of key vitamins and minerals, also known as micronutrients. While global in scale, the prevalence of micronutrient deficiencies is particularly high in South Asia despite recent successes in economic growth, agricultural output and health care. The present paper reviews the most recent evidence on patterns and trends of hidden hunger across the region, with a focus on the most significant deficiencies - iodine, Fe, vitamin A and Zn - and interprets these in terms of health and economic consequences. The challenge for South Asian policy makers is to invest in actions that can cost-effectively resolve chronic nutrient gaps facing millions of households. Appropriate solutions are available today, so governments should build on evidence-based successes that combine targeted health system delivery of quality services with carefully designed multisector actions that help promote healthier diets, reduce poverty and ensure social protection simultaneously.

A life-course approach to health: synergy with sustainable development goals.

A life-course approach to health encompasses strategies across individuals’ lives that optimize their functional ability (taking into account the interdependence of individual, social, environmental, temporal and intergenerational factors), thereby enabling well-being and the realization of rights. The approach is a perfect fit with efforts to achieve universal health coverage and meet the sustainable development goals (SDGs). Properly applied, a life-course approach can increase the effectiveness of the former and help realize the vision of the latter, especially in ensuring health and well-being for all at all ages. Its implementation requires a shared understanding by individuals and societies of how health is shaped by multiple factors throughout life and across generations. Most studies have focused on noncommunicable disease and ageing populations in high-income countries and on epidemiological, theoretical and clinical issues. The aim of this article is to show how the life-course approach to health can be extended to all age groups, health topics and countries by building on a synthesis of existing scientific evidence, experience in different countries and advances in health strategies and programmes. A conceptual framework for the approach is presented along with implications for implementation in the areas of: (i) policy and investment; (ii) health services and systems; (iii) local, multisectoral and multistakeholder action; and (iv) measurement, monitoring and research. The SDGs provide a unique context for applying a holistic, multisectoral approach to achieving transformative outcomes for people, prosperity and the environment. A life-course approach can reinforce these efforts, particularly given its emphasis on rights and equity.

Funkcje partnerstwa lokalnego w rozwoju obszarów wiejskich

Local partnership acts as a platform for cooperation between the three key sectors of the rural economy: public, social and economic. One of the tangible manifestations of local partnerships are local action groups. The local action group is an example of a local partnership striving to design and implement development projects in a given area. The essence of the undertakings concerned should flow from the interests of the whole community and of the individual partners forming the group. Cooperation between local government representatives, entrepreneurs and the local community offers a variety of benefits. Literature mentions in particular the integration of local communities, development of public-private partnerships, development of economic and social initiatives, activation of local communities, economic development of local government units. A local development strategy is based on the local community driven development instrument in the form of local action groups. Developed and implemented in a bottom-up way through integrated and multi-sectoral actions, is to contribute to the visibility of local factors. The multiplicity of opportunities to apply for action support points to many functions that a local action group performs while implementing a local development strategy. These are primarily business, ecological and cultural functions.

Non-communicable disease prevention in Nepal: systemic challenges and future directions.

Developing countries such as Nepal are experiencing a double burden of communicable and non-communicable diseases (NCDs) resulting in social and economic losses. In Nepal, more than half of the disease burden is due to NCDs. The major NCDs in Nepal are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. Behavioural factors such as tobacco use, alcohol consumption, physical inactivity and unhealthy diet are driving the epidemic of NCDs, which are further influenced by social, economic and environmental determinants. The health system of Nepal has not been able to address the ever-increasing burden of NCDs. With the formulation of the Multisectoral Action Plan for Prevention and Control of NCDs 2014-2020, there has been some hope for tackling the NCDs and their social determinants in Nepal through a primary prevention approach. This paper discusses the systemic challenges and recommends two key actions for the prevention and control of NCDs in Nepal.

Using Systems Thinking to train future leaders in global health

ABSTRACTSystems Thinking provides a useful set of concepts and tools that can be used to train students to be effective and innovative global health leaders in an ever-changing and often chaotic world. This paper describes an experiential, multi-disciplinary curriculum that uses Systems Thinking to frame and analyse global health policies and practices. The curriculum uses case studies and hands-on activities to deepen students’ understanding of the following concepts: complex adaptive systems, dynamic complexity, inter-relationships, feedback loops, policy resistance, mental models, boundary critique, leverage points, and multi-disciplinary, multi-sectoral, and multi-stakeholder thinking and action. A sample of Systems Thinking tools for analysing global health policies and practices are also introduced.

Food insecurity and ART adherence in Swaziland: the case for coordinated faith-based and multi-sectoral action

ABSTRACTFaith-based organisations (FBOs) have long been involved in HIV and AIDS impact mitigation and humanitarian relief, but most are not equipped to intervene in the structural drivers of food insecurity and attendant health inequities. Acknowledging limitations is as paramount a task for organisational effectiveness as maximising strengths. This article reports findings from a study of HIV-positive care supporters who volunteer with a church-run home-based care organisation in Swaziland. The article seeks to assess the impact of chronic food insecurity on antiretroviral adherence practices and how these individuals manage daily food shortages. Findings highlight the limited capacities of FBOs in highly vulnerable settings and the imperative for international and governmental coordination.

Perspectives on the coordination of multisectoral nutrition in Mozambique and an emerging framework

Multisectoral approaches represent a prominent ideological consensus, influenced by historical roots and the current political, financial and institutional landscape, to address the multi-faceted and complex causes of most nutrition, public health and food problems. However, the implementation of multisectoral approaches presents tremendous challenges; one of the most often cited problems, in the literature and by practitioners, is coordination. This study investigates the perspectives of key national leaders on a range of issues regarding the coordination of a Multisectoral Action Plan for the Reduction of Chronic Undernutrition (PAMRDC) in Mozambique. Within this policy group, the principal researcher played the role of a researcher-participant for 14months, and used Q methodology with a total of 21 key national leaders who had been actively engaged in coordination groups at the central level. Participants sorted 54 subjective statements on a range of issues that were present in the current national discourse. The results revealed four distinct perspectives. The Implementation perspective (n=12) prioritized concrete actions to advance the operationalization of the plan, based on a guidance-based approach from the central level to the lower administrative levels. The Advocacy perspective (n=3) emphasized advocacy to increase politicians’ awareness of the problem and of potential solutions to enhance political commitment. The Structuralist perspective (n=3) was concerned with the development of structures and mechanisms to facilitate coordination, funding and improving communication between the government and donors. The People-centered perspective (n=3) focused on the importance of mobilizing individuals to compensate for the sub-optimal structures and processes for coordination. Areas of convergence across the perspectives included: low capacity and skills that limit the work; the agency in charge of coordination (SETSAN) should exercise an increased leadership to facilitate the multisectoral work; and SETSAN should advocate to mobilize politicians and donors for resources. Areas of divergence related to the type of guidance from national to sub-national levels (prescriptive or not) and the functions to be carried out by SETSAN. This study highlights lack of clarity on the meaning of coordination and on the functions of the multisectoral coordination body that appear to arise for two reasons: the lack of an explicit and shared framework for the policy process and the complex nature of coordination itself. These results are examined through the lenses of several related literatures, including governance, public policy and political economy of nutrition, leading to a three-dimensional conceptual framework for coordination that distinguishes the coordination space, forms, and instruments. Global guidance, such as provided through the SUN movement, could support countries in overcoming their coordination challenges by facilitating an analysis of their decision-making processes in order to choose the functions for the coordination body based on a shared understanding of countries’ needs, context and opportunities. This paper moves the field beyond a broad consideration of horizontal and vertical coordination within multisectoral initiatives.

Trends in obesity and diabetes across Africa from 1980 to 2014: an analysis of pooled population-based studies.

BackgroundThe 2016 Dar Es Salaam Call to Action on Diabetes and Other non-communicable diseases (NCDs) advocates national multi-sectoral NCD strategies and action plans based on available data and information from countries of sub-Saharan Africa and beyond. We estimated trends from 1980 to 2014 in age-standardized mean body mass index (BMI) and diabetes prevalence in these countries, in order to assess the co-progression and assist policy formulation.MethodsWe pooled data from African and worldwide population-based studies which measured height, weight and biomarkers to assess diabetes status in adults aged ≥ 18 years. A Bayesian hierarchical model was used to estimate trends by sex for 200 countries and territories including 53 countries across five African regions (central, eastern, northern, southern and western), in mean BMI and diabetes prevalence (defined as either fasting plasma glucose of ≥ 7.0 mmol/l, history of diabetes diagnosis, or use of insulin or oral glucose control agents).ResultsAfrican data came from 245 population-based surveys (1.2 million participants) for BMI and 76 surveys (182 000 participants) for diabetes prevalence estimates. Countries with the highest number of data sources for BMI were South Africa (n = 17), Nigeria (n = 15) and Egypt (n = 13); and for diabetes estimates, Tanzania (n = 8), Tunisia (n = 7), and Cameroon, Egypt and South Africa (all n = 6). The age-standardized mean BMI increased from 21.0 kg/m2 (95% credible interval: 20.3–21.7) to 23.0 kg/m2 (22.7–23.3) in men, and from 21.9 kg/m2 (21.3–22.5) to 24.9 kg/m2 (24.6–25.1) in women. The age-standardized prevalence of diabetes increased from 3.4% (1.5–6.3) to 8.5% (6.5–10.8) in men, and from 4.1% (2.0–7.5) to 8.9% (6.9–11.2) in women. Estimates in northern and southern regions were mostly higher than the global average; those in central, eastern and western regions were lower than global averages. A positive association (correlation coefficient ≃ 0.9) was observed between mean BMI and diabetes prevalence in both sexes in 1980 and 2014.ConclusionsThese estimates, based on limited data sources, confirm the rapidly increasing burden of diabetes in Africa. This rise is being driven, at least in part, by increasing adiposity, with regional variations in observed trends. African countries’ efforts to prevent and control diabetes and obesity should integrate the setting up of reliable monitoring systems, consistent with the World Health Organization’s Global Monitoring System Framework.

Governing multisectoral action for health in low- and middle-income countries.

Kumanan Rasanathan and colleagues argue that the potential of multisectoral collaboration for improving health remains untapped in many low- and middle-income countries.

The role of pulses in sustainable and healthy food systems.

Improving nutrition is a development priority, particularly in low- and middle-income countries (LMICs) in Africa and South Asia, in which there is a persistent burden of undernutrition and increasing obesity. Healthy food systems can play a necessary role, aligned with other multisectoral actions, in addressing this challenge. Contributing to improved nutrition and health outcomes through food-based solutions is complex. In considering the role that pulses can play in addressing this challenge, there are useful conceptual frameworks and emerging lessons. National food systems in LMICs provide limited diet quality. Foods for a healthy diet may be produced locally, but they increasingly rely on improved markets and trade. What might be done to transform food systems for healthier diets, and what role can pulses play? Food systems innovations will require a convergence of technical innovation with smarter institutional arrangements and more effective policies and regulations. In many countries in Africa and South Asia, pulses can make important contributions to healthier diets. Options for supporting pulses to make a greater contribution to healthier diets include increasing the efficiency of pulse supply chains, creating more effective public-private institutional arrangements for innovation, and establishing policies, regulations, and investments that are nutrition sensitive.

Redefining public health leadership in the sustainable development goal era.

Adoption of the Sustainable Development Goals (SDGs) by member states of the United Nations (UN) has set a new agenda for public health action at national and global levels. The changed context calls for a reframing of what constitutes effective leadership in public health, through a construct that reflects the interdependence of leadership at multiple levels across the health system and its partners in other sectors. This is especially important in the context of Low and Middle Income Countries (LMICs) that are facing complex demographic and epidemiological transitions. The health system needs to exercise leadership that effectively mobilises all its resources for maximising health impact, and channels trans-disciplinary learning into well-coordinated multi-sectoral action on the wider determinants of health. Leadership is essential not only at the level of inspirational individuals who can create collective vision and commitment but also at the level of supportive institutions situated in or aligned to the health system. In turn, the health system as a whole has to exercise leadership that advances public health in the framework of sustainable development. This commentary examines the desirable attributes of effective leadership at each of these levels and explores the nature of their inter-dependence.

Multi-sectoral action for child safety-a European study exploring implicated sectors.

Injury to children in Europe, resulting in both death and disability, constitutes a significant burden on individuals, families and society. Inequalities between high and low-income countries are growing. The World Health Organisation Health 2020 strategy calls for inter-sectoral collaboration to address injury in Europe and advocates the whole of government and whole of society approaches to wicked problems. In this study we explore which sectors (e.g. health, transport, education) are relevant for four domains of child safety (intentional injury, water, road and home safety). We used the organigraph methodology, originally developed to demonstrate how organizations work, to describe the governance of child safety interventions. Members of the European Child Safety Alliance, working in the field of child safety in 24 European countries, drew organigraphs of evidence-based interventions. They included the different actors involved and the processes between them. We analyzed the organigraphs by counting the actors presented and categorizing them into sectors using a pre-defined analysis framework. We received 44 organigraphs from participants in 24 countries. Twenty-seven sectors were identified across the four domains. Nine of the 27 identified sectors were classified as 'core sectors' (education, health, home affairs, justice, media, recreation, research, social/welfare services and consumers). This study reveals the multi-sectoral nature of child safety in practice. It provides information for stakeholders working in child safety to help them implement inter-sectoral child safety interventions taking a whole-of-government and whole-of-society approach to health governance.

A communication framework for climatic risk and enhanced green growth in the eastern coast of Ghana

Progresses made in global responses to climate change shows that adaptation is gradually finding its way into development planning, yet delays are generally expected from competing priorities of several sectors, policy and knowledge challenges. To understand these dynamics, a pathway for enhanced climatic risk communication, which is a form of a non-structural adaptation, was analyzed in Ghana’s coastal zones. Two learning platforms, the Community-based Risk Screening Tool for Adaptation and Livelihoods (CRiSTAL), and U-Learning (Theory U-Process) were used to engage the state level policy-making process in governing development within coastal zones in the face of increased climatic risks and climate change impacts. Local livelihood priorities showed that a national level development planning framework that excluded local contexts of climatic risks face possible maladaptation. Subsequently the process that was engaged in the local contextualization of climatic risks and development in selected Districts culminated in the consensus framework, Coastal Zone Green Growth (CZGG), informed mostly by concerns over clean energy usage and ecologically compatible use of coastal resources. Therefore the CZGG potentially provides co-benefits for enhanced ecosystem services, livelihoods and adaptation. Thus, it constitutes a denominator for measuring climatic risks and adaptation to potentially inform the policy-making process towards sustainable coastal zone management practices. Except for the desired goals of CZGG being far reaching and futuristic, they overlapped with goals of the adaptation strategies of the local population, which are similar to development goals. Therefore communicating localized contexts of coastal climatic risks of which sea level rise is seen often as remote to planning, could strengthen risk management in integrated coastal zone management (ICZM) and enhance resilience of vulnerable communities. However, this will require the designation of a body which is accustomed to the local issues to facilitate, harmonize and coordinate multi-sector actions and diverse stakeholders’ interests for the CZGG to become a reality in contributing to ICZM in Ghana.

Implementing a multi-sectoral response to HIV: a case study of AIDS councils in the Mpumalanga Province, South Africa

ABSTRACT Background: A multi-sectoral response is advocated by international organisations as a good strategy to address the multiple drivers and impact of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and was historically mandated as a condition of funding. In March 2017, the South African National AIDS Council (SANAC) launched the latest 5 year National Strategic Plan (NSP) to address HIV, sexually transmitted infections and tuberculosis. As with previous iterations, the NSP calls for multi-sectoral action (MSA) and mandates AIDS councils (ACs) at different levels to coordinate its implementation. Efforts have been made to advocate for the adoption of MSA in South Africa, yet evaluation of these efforts is currently limited. Objective: This paper assesses the implementation of a multi-sectoral response to HIV in South Africa, through a case study of the Mpumalanga Province. Methods: We identified and reviewed key policy documents, conducted 12 interviews and held six focus group discussions. We also drew on our involvement, through participant observation, in the development of NSPs and in AC meetings. Results: SANAC is struggling to provide much-needed support to provincial, district and local ACs. Therefore, most ACs are generally weak and failing to implement MSA. Membership is voluntary, there is a lack of sustained commitment and they do not include representatives from all sectors. There is little capacity to undertake the activities necessary for coordinating the implementation of MSA, and unclear roles and responsibilities within ACs result in divisions and tension between sectors. There is inadequate senior political leadership and funding to facilitate effective implementation of MSA. Conclusion: We identified three interventions that we argue are required to support the effective implementation of MSA: strengthening and stabilising the SANAC structure; building capacity of ACs; and creating an enabling environment for effective implementation of MSA through political leadership, support and resourcing of the HIV response.

Going beyond the health sector for prevention and control of noncommunicable diseases: Review of multisectoral actions in health policies

Noncommunicable diseases (NCDs) are a major cause of death and disability worldwide. Many of the determinants of NCDs go beyond the purview of the health sector. Hence, the involvement of nonhealth stakeholders along with the health sectors is important in the planning and implementation of programs for the prevention and control of NCDs. The current review aims to study the existing literature, thereby provide a background for further action in prevention and control of NCDs at a policy level. It was seen that the World Health Organization (WHO) Global Action Plan in 2013 led to the development of multisectoral action plans (MSAPs) in many of the member states of the WHO. However, for effective implementation of MSAPs, a strong leadership role and mechanism for partnership must be provided by the government. Furthermore, they can be strengthened by monitoring which ensures the accountability of each sector.

Extent of multisectoral participation for noncommunicable diseases: Outcomes of roundtable discussions during world noncommunicable diseases congress

India was first in delineating Global Action Plan in 2013 with the monitoring framework having specific targets and indicators to overcome noncommunicable diseases (NCDs) burden, which entails the requirement of vital phase that is multisectoral participation of different sectors for its implementation. Therefore, for involving different sectors, there is a requirement of the multisectoral action plan which can be helpful in providing the environment of buttress footprint, i.e., all stakeholders can draw on their collective core accomplishment to create a more comprehensive deck of potential in achieving a common goal. Initial case study was done through interviewing total 28 stakeholders to analyze the situation, perspective, and the extent of the participation of the different stakeholders from various sectors, toward the multisectoral participation in Chandigarh using World Health Organization (WHO) NCD map tool. Following the case study analysis, roundtable meeting was done; total 21 stakeholders participated in meeting, which was moderated by the WHO Coordinator NCD, SEARO region. Results of the case study assessing the multisectoral participation in Chandigarh and outcomes of the roundtable are presented in this manuscript. Case study emanates that majority of the stakeholders answering lack of coordination mainly affecting the success of any program and outcomes of the roundtable meeting underlined the requirement of proper coordination mechanism, strengthening of surveillance, implementation, monitoring and evaluation of NCD programs, political will by advocacy, and its prioritization.

Socioeconomic and demographic trends in the prevalence of type 2 diabetes in India

AbstractNoncommunicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression. The four main types of NCDs are cardiovascular diseases (such as heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes. The rapid demographic and epidemiologic transition that India is facing today is paralleled by a massive increase in NCD prevalence, of which diabetes remains the most dominant. Besides genetic and environmental factors, an increase in life expectancy, urbanization, influenced unhealthy lifestyle changes, affluence associated with dietary excess, and reduced physical activity appear to be major drivers for increased burden of diabetes in India. Inappropriate nutrition and physical inactivity lead to obesity, a positive predictor for diabetes. Moreover, early onset of diabetes accompanied by prevailing poverty, low awareness, and poor health consciousness across socioeconomic and demographic strata is reflected in the large burden of undiagnosed cases of diabetes. In addition, reversal of socioeconomic gradient of disease burden observed in India can have serious health and financial implications on individual and healthcare system, which, if left unaddressed, may result in an adverse impact on the nation's economy. Keeping in view, a major shift in India's burden of disease, there is an imperative need for robust, systematic measures for data reporting supported by effective public healthcare interventions to reduce the burden of diabetes. Comprehensive multisectoral actions prioritizing identification of risk factors, early diagnosis, and effective implementation of cost-effective interventions can curb the epidemic of diabetes. A multifaceted approach for implementation of evidence-based policy measures involving various departments of the government and nongovernmental agencies is required to address both preventive and curative aspects of diabetes management. Policies that ensure better surveillance and increase in access to affordable and essential medicines providing universal health coverage should be developed. Policymakers should take lead in the development or strengthening the existing policies and see that they are not only implemented but also evaluated for their effectiveness. A strong commitment from both public and private sectors toward implementation and intensification of population-based prevention strategies through proven programs and policies is required to address the growing burden of diabetes.