Good governance
Definition and mandate
The breadth and ambition of the 2030 Agenda for Sustainable Development, and the inter-connected nature of the goals, call for national responses that build synergies across sectors. Now, more than ever, there is momentum for ‘whole-of-government’ responses, ensuring greater coordination and coherence of policies.
This approach is based on the rationale that health is determined by multiple factors outside the direct control of the health sector e.g. education, income, and an individual living conditions and that decisions made in other sectors can affect health of individuals and shape patterns of disease distribution and mortality.
Health gains, as well as the realization of health as a fundamental human right and health equity, require that policy making in other sectors routinely consider health outcomes, including benefits, harms, and health related-costs.
Action across sectors for health was the powerful conclusion set forth in the Helsinki Statement on Health in All Policies (2014), the foundation for which was laid over the years by the Alma Ata Declaration on Primary Health Care (1978), the Ottawa Charter for Health Promotion (1986), the Rio Political Declaration on the Social Determinants of Health (2011) and numerous other high-level political resolutions and fora. The WHO Framework for Country Action across Sectors for Health and Health Equity1 provides Member States with a guiding framework for realizing intersectoral action for health.
Critically, action across sectors for health and health equity is not just about achieving better health outcomes through securing ‘favours’ from other sectors. Rather, it is about the health sector supporting and collaborating with other sectors to develop and implement policies, programmes and projects in their own remit, in a way that optimizes co-benefits for all sectors involved. The broad and interlinked Sustainable Development Goals (SDGs) make this more possible and indeed necessary than ever before, while presenting unique challenges. At the same time, health threats such as Ebola have renewed attention to how weak health systems pose global security threats, and the need to recognize health promotion as a foreign policy and security priority as well.
From Ottawa to Shanghai & the sustainable development agenda
Thirty years ago, the Ottawa Charter for Health Promotion recognized the need to enable people to increase control over and to improve their health and well-being by ensuring healthier, sustainable environments where people live, work, study and play. Social justice and equity were highlighted as core foundations for health, and there was agreement that health promotion is not simply the responsibility of the health sector.
Subsequent WHO global health promotion conferences have reiterated these elements as key for health promotion.
The 2030 Agenda for Sustainable Development, the world’s ambitious and universal “plan of action for people, planet and prosperity”, includes 17 Goals, 169 targets and 231 initial indicators. The Agenda offers a new opportunity to involve multiple stakeholders to ensure that all people can fulfil their potential – to live in health and with dignity and equality.
With this in mind, the theme of the 9th Global Conference on Health Promotion, “Health Promotion in the Sustainable Development Goals” is both timely and necessary to ensure policy-coherence and alignment of agendas for action. The slogan: “Health for All and All for Health” captures the commitment to leave no one behind and to involve all actors in a new global partnership to achieve this transformative Agenda.
Health is a precondition for all three dimensions of sustainable development – social, economic and environmental – and action on the social and environmental determinants of health is in turn critical to creating inclusive, equitable, economically productive and healthy societies2.
The mutually reinforcing relationship between health and development makes realizing synergies both desirable and necessary. However, the adoption of truly integrated ‘whole-of-government’ approaches to support action across sectors is yet to be achieved in many countries, owing to a range of challenges described below. Legislation, rules and regulations are important instruments for governments to use in fulfilling their responsibility to prevent disease and promote population health, and to protect people from social, economic and environmental harms that threaten the right to health.
But, as Table 1 illustrates, the integrated and indivisible nature of Agenda 2030 offers a game-changing opportunity to elevate policy coherence and efficiencies above siloed and fragmented approaches to health, health equity and development. Though needed in all countries, realizing synergies across sectors is particularly important in low-income countries, where resource constraints make finding win-wins across sectors even more appealing. The next section provides concrete examples of how action across sectors can simultaneously advance health, health equity and other sustainable development goals.
Good governance and the SDGs
No poverty
Poverty and poor health are interlinked and mutually reinforcing. People living in poverty are disproportionately exposed to various risk factors for poor health in their homes, at work, and in their communities. In the
absence of universal health coverage, the poor have reduced access to critical treatment and prevention services. Catastrophic health conditions, in turn, drive people into poverty, especially in the absence of adequate and affordable social protection
since they are often forced to leave the labour market. Any policy framework that is serious about poverty eradication must actively seek synergies between health promotion and social welfare sectors. Cash transfer schemes that are health-sensitive
and inclusive are an exemplary win-win. Cash transfers have been shown to achieve a range of impacts in health, spanning nutrition, maternal and child health, health service demand and uptake, and, increasingly, HIV and STI prevention.
Quality education
Coordination between the health and education sectors can advance the goals of both simultaneously. Schools offer an ideal setting for health promotion. Messages related to diet or exercise, for example, can
be promoted and reinforced to help improve students’ health and nutritional status while also contributing to improved cognitive function, attentiveness and test scores. Similarly, primary school deworming efforts within a sanitation
response have been shown to have both health and nutritional benefits, while also reducing school absenteeism. In Kenya, deworming efforts have been shown to be more cost-effective than alternative methods for encouraging school participation.
Gender equality
Action on health and health equity must address the gender inequities that hold back women, their families and societies. Coordination between the health and gender sectors can ensure that women have equal
access to essential health and medical services; have decent jobs with equal pay; are empowered to make decisions over their lives, bodies, and finances; and are not inequitably exposed to health risks because of their gender (whether from
household chores, second-hand smoke, or gender-based violence). The inter-generational health benefits of investing in women’s empowerment have also been well-documented. For example, putting cash in the hands of women is a remarkably
strong cross-cutting investment that can lift the health of women and their families while tackling a range of other economic and non-economic gender inequities.
Affordable and clean energy
There are numerous win-win innovations in health and sustainable energy that have emerged in recent years through cross-sectoral collaboration. For example, the Global Alliance for Clean Cookstoves
introduces fuel-efficient stoves to increase energy efficiency and reduce deforestation while also reducing indoor air pollution, a major noncommunicable disease (NCD) risk factor. Since women and young children are often disproportionately
and inequitably exposed to smoke from stoves, there are significant gender and health equity benefits. Meanwhile, equipping solar panels at health centres can ensure access to affordable, reliable and modern energy services, while also allowing
health clinics to maintain cold chains and remain operational and connected.
Decent work and economic growth
Better health leads to more productive societies, and, where economic growth is inclusive, this, in turn, leads to better health outcomes. Taxation of health-harming products is a powerful
win-win synergy between the health and economic sectors. Such taxes enable people to be healthier and economies more productive, while raising government revenue and reducing health care costs down the road. Conversely, where health is sacrificed
for perceived economic gain – whether in working conditions, tobacco production or deregulated food environments – inequities and disparities widen, making inclusive economic growth harder – not easier – to achieve.
Reduced inequalities
Action across sectors for health and health equity aims to enhance opportunities amongst individuals within countries. It is a key approach of health promotion that seeks to mainstream health in all policies
tackling differences in socioeconomic status, gender, ethnicity, disability status and sexuality, which may deepen health inequities, if not addressed. Action across sectors for health should emphasize that the right to health is a basic
human right. For example the school health programme/services provided through the education sector, is an extension of the primary health care to school settings, which provide children with essential health care services and has broader
implications in advancing fair and equal societies for all.
Sustainable cities and communities
Urbanization offers significant opportunities for improving health but, where it is inadequately managed, urbanization can also pose unique health risks, such as increased exposure to NCD
risk factors. As detailed in the WHO and UNDP policy brief on Healthy cities, multiple synergies are possible across health, housing, sanitation, air quality, transport and urban planning. Realizing these synergies requires municipal governments
to understand health threats and map epidemics, and then develop effective and equitable multisectoral policies and plans that address these while supporting broader efforts to make cities inclusive, safe, resilient and sustainable.
Peace, justice and strong institutions
Whether through national AIDS bodies, national coordinating mechanisms for tobacco control, multisectoral NCD committees, or intersectoral coordination platforms for global health crises, action
across sectors is, at its core, about better governance. This includes increased policy coherence, better conflict of interest management, and improved co-benefit analysis, planning and financing. In this way action across sectors promotes effective,
accountable, and transparent institutions at all levels.
Good governance – the case of tobacco control
Tobacco use and inequities go hand-in-hand. In terms of consumption, the poorest are more likely to use tobacco in every region, widening health inequities within countries.
The WHO Framework Convention on Tobacco Control (WHO FCTC) provides a compendium of cost-effective policies but most of these policies require coordinated action with sectors other than health. Tobacco taxation, by far one of the most effective tobacco control measures, is an example. Article 6 of the WHO FCTC calls for the use of price and tax measures for tobacco control, and paragraph 32 of the Addis Ababa Action Agenda1 underscores the importance of tobacco taxation in reducing tobacco use but also as a potential revenue stream for financing development.
Taxing tobacco products to realize these benefits requires that finance, customs and health officials come together to develop optimal and mutually beneficial frameworks.
Taxing tobacco in the Philippines
In 2012, the Philippines passed its landmark Sin Tax Reform Law2. This legislation simplified the country’s previously complex, multi-tiered tobacco excise tax structure and substantively increased excise rates for cigarettes in the lowest tier by 341 percent in 2013.
The tax is reducing smoking and improving health, namely by preventing young people from starting to smoke and encouraging others to quit or smoke less often. It is also generating significant revenue for the government.
The incremental revenues generated by the Sin Tax Reform Law in the first three years of implementation totalled PHP 174.5 billion (US$3.9 billion), about eighty percent of which is accounted for by tobacco.
Public support for tobacco taxation is generally high, even amongst smokers. It is even higher where governments spend revenue from the tax transparently, and especially where they reinvest the revenues back into tobacco control and or health promotion broadly3.
The Philippines has done both. It earmarks about 15 percent of incremental revenue collected from tobacco taxes in the Sin Tax Law to support alternative livelihoods for tobacco farmers and workers in tobacco growing provinces, in line with Articles 17 and 18 of the WHO FCTC.
The remaining – and vast majority – of the incremental revenue is used as a source of sustainable financing for the country’s Universal Health Care Programme, and to strengthen health systems. Incremental revenues generated by the Sin Tax Law has enabled the Government to subsidize the health insurance premiums of 15.4 million poor primary members in 2015, up from only 5.2 million poor members of the programme registered in 2012.
Noteworthy is that Philippines’ Sin Tax Reform Law also taxes alcohol, the harmful use of which is another behavioural risk factor for NCDs including diabetes, cancer and cardiovascular disease.
The Philippines’ decision to earmark revenue to support alternative livelihoods for tobacco growers allows the country to address the health and developmental consequences of tobacco use from both the demand and supply-side of the equation – this while addressing the poor working conditions and health risks to which tobacco growers, many of whom are children, are frequently exposed.
Supplying these workers with alternative economic activities, which have been found to be more lucrative for workers than tobacco growing in countries such as Indonesia4, directly advances SDG 8 on decent work and economic growth.
And because tobacco farming is land-intensive and often utilizes large amounts of fertilizer, herbicide and pesticide, alternative economic activities to tobacco growing can also support environmental objectives. Promoting these alternative activities, therefore, requires the health sector to coordinate with agricultural, planning, environment and other sectors to advance multiple SDGs simultaneously.
Supporting alternatives to tobacco growing in Kenya
As part of a field trial initiated in 2006 and supported by the International Development Research Centre (IDRC-Canada) and South Eastern University College (SEUCO), a number of farmers in different regions of Kenya committed to switch from tobacco growing to growing bamboo. Bamboo was selected for experimentation because it has multiple economic uses and was reportedly well-suited to the soil and climate found in the region.
Estimates of the comparative net value of the two crops – tobacco and bamboo – showed rates of return to be more than 300 percent higher for bamboo farmers. While not all farmers in the trial remained by 2013, the project successfully established bamboo processing microenterprises and farmers’ cooperatives in each of the 4 four study districts, and demonstrated the ability of tobacco growing farmers to shift to alternative cropping while actually improving their livelihoods.
2. Briefer on the Sin Tax Law (R.A. No. 10351 “An Act Restructuring the Excise Tax on Alcohol and Tobacco Products”).
3. WHO. 2015. “Global status report on road safety 2015.”
Good governance – the case of road safety
The UN General Assembly proclaimed 2011-2020 the Decade of Action for Road Safety1, recognizing that each year more than 1.24 million people die and 50 million are injured on the world’s roads. Road safety is also an issue of equity.
Ninety percent of road traffic deaths occur in low– and middle-income countries, even though these countries are home to just 54 percent of the global car fleet2, with children and young people most affected by road traffic-related collisions3.
Half of all road traffic deaths are amongst vulnerable road users, such as pedestrians, cyclists and motorcyclists. Beyond the costs to human health, an estimated 3 percent of GDP is lost to road traffic deaths and injuries globally.
Addressing the preventable problem of inadequate road safety requires the dedicated action of multiple ministries, most notably law, planning, transport, education, public information and health.
The range of measures to ensure road safety includes improving the built environment (e.g. safer road design, regulating sidewalks and traffic lights, introducing safe bicycle lanes), law enforcement and education to increase seatbelt use and helmet wearing while reducing speeding and drink-driving, better vehicle standards, and improved post-crash response.
Road safety measures that provide safer, more sustainable public transport options are also particularly promising and can support synergies between health, transport and carbon emission reduction targets.
Improved road safety in Viet Nam4
Since 2010, Viet Nam’s multisectoral National Traffic Safety Committee has been supported by WHO and other partners to implement evidence-based interventions to reduce road traffic injuries (a leading cause of death and disability in Viet Nam).
Interventions implemented under the auspices of the Bloomberg Initiative for Global Road Safety, from motorcycle helmet wearing to the prevention of drink-driving, involved different ministries (Transport, Public Security, Health).
From 2010 to 2013, these multisectoral efforts led to a significant reduction in road traffic mortality in the provinces of Ha Nam and Ninh Binh (5 percent and 26 percent respectively)5.
2. WHO. 2015. “Global status report on road safety 2015.”
3. WHO. 2014. “Health statistics and information systems: Estimates for 2000-2012.”
4. WHO. “WHO Framework for Country Action Across Sectors for Health and Health Equity: Selected Case Studies.” Updated on 12 May 2015
PDF, 175kb
5. “National mortality reporting from Ministry of Health, Viet Nam.” Hanoi, Viet Nam, Ministry of Health, 2010, 2013.
Good governance – challenges, opportunities and UN support
The promotion of action across sectors is not an endpoint in itself but rather an important and useful approach to attaining the SDGs. Yet the utility and plain good sense of collaborating across sectors in pursuit of coherent and efficient policy can sometimes take a backseat to ingrained challenges, ranging from departmentalism to conscious antagonism, from systemic misalignment of health and commercial objectives to non-health sectors of government not having sufficient information on why health matters for their core objectives.
Even where non-health sectors are ready and willing to support action across sectors for health and health equity, there are often gaps in understanding which evidence-based interventions can best achieve synergies across sectors.
Strengthening multisectoral governance, for example through establishing the type of intersectoral coordination structures used to address road safety in Viet Nam, can help overcome many of these challenges. So too can building the capacity of the health sector, and public health practitioners more broadly, to better understand and weigh the pros and cons of working with non-health sectors/stakeholders.
Though action across sectors for health and health equity is the responsibility of entire governments, the health sector must often take a lead role in promoting multisectoral action from both a health and non-health sector perspective. As decades of experiences in responding to AIDS demonstrate, health can be a powerful pathfinder for whole-of-government approaches that lift not just health but social and economic objectives more broadly. Concurrently, it will be essential to build the capacity of health systems at the country, regional and global levels to address the social, economic and environmental determinants of health.
As we shift towards effective application of the action across sectors approach, the WHO Framework for Country Action across Sectors for Health and Health Equity, together with the number of technical documents, plans, tools and how-to-guides WHO is developing with partners, such as the PAHO Plan of Action on Health in All Policies (HiAP), HiAP Training Manual, and multisectoral briefs on NCDs with UNDP, offer countries more detailed guidance.
Efforts are needed on the part of all relevant stakeholders to examine the impact of the action across sector approach, for example by identifying quantifiable markers for reporting progress, giving an account of the achievements thus far, and strengthening the evidence base of the many models and methods that promote action across sectors. Buy-in by countries at all levels of development at the UNGA and WHA will be critical for ingraining action across sectors as the new and preferred approach in the Agenda 2030 era.
Financing across sectors for health and development synergies
The SDGs demand not just synergies in programming but also in financing for development. With countries increasingly expected to finance their development priorities domestically, identifying and financing high-value cross cutting interventions that can achieve multiple goals and targets simultaneously has become more important than ever.
Social protection is one such intervention; it helps reduce poverty, reduce economic and gender inequalities, as well as exclusion, build human capital and advance human development, through direct benefits to education and health outcomes.1
But high-value interventions like social protection are often under-funded and achieve less than optimum coverage, largely because conventional evaluation methods fail to capture their range of costs and benefits that in reality are distributed to multiple sectors.
UNDP is working with the STRIVE Consortium and other partners to support governments in sub-Saharan Africa to identify and fund these interventions more efficiently, through an appropriate pooling of resources across benefiting sectors, with contributions guided by each sector’s valuation and willingness to pay for specific results.
The United Nations Development Group (UNDG) has included this “cross-sectoral co-financing” approach as a key financing strategy under MAPS (Mainstreaming, Acceleration and Policy Support) – the dedicated, common approach of over 30 UN agencies under the auspices of UNDG to support SDG implementation in countries.
1 Cash transfers have consistently been shown to lead to better outcomes in nutrition and maternal and child health. They also increase demand for, and uptake of, essential health and medical services, making them a critical demand-side structural intervention for achieving UHC.
Moving forward: A plan for the next fifteen years
The Agenda 2030 will require a new way of working, harnessing the considerable synergies across goals. Moreover, taking into account the ambition and broad scope of Agenda 2030, progress will only be achieved by bringing together a range of stakeholders, as envisioned in Goal 17. This means moving beyond stand-alone vertical approaches to integrated ones that address multiple goals and targets across different sectors.
Examples of the roles for stakeholders in promoting action across sectors for health, health equity and the SDGs include:
Government
Break down silos for planning and financing; assess existing governance platforms’ ability to absorb and/or be adapted for other health and development issues, including health crises; establish multisectoral mechanisms as needed and strengthen the capacity of health ministries to take a leadership and coordinating role.
Civil society
Work together to bring different CSO expertise, experiences and capacities to bear in action across sectors and build alliances across social movements.
Media (including social media)
Support the convergence of conversations and help build political capital for multisectoral action that is good for the planet and its people.
Organizations of the UN system
Support multisectoral action with a mirrored interagency response, providing mainstreaming, acceleration and policy support1, including to domesticate the SDGs in line with national targets and objectives, as requested.
Community leaders
Advocate for greater policy coherence and coordination at the local level to address issues of local concern efficiently, and to advance sustainable human development.
Research and academic institutions
Expand the evidence base for promoting action across sectors, help to fill key information gaps and promote evidence-based win-win practices.
With the political currency that ‘whole-of-government’ approaches now enjoy, action across sectors for health and health equity provides a strong mechanism for ensuring that all aspects of health promotion are integrated into other sectors’ policies, programmes, and service delivery platforms.
The SDGs present not just a historic challenge but also a major opportunity - to drive home the concepts that have been recognized from Ottawa to Helsinki, from Health in All Policies, to whole-of-government approaches, to action across sectors, to multisectoral action – that by working together for win-wins, and pooling resources, we can achieve far more together than we can on our own.