by Richard Skolnik, MPA
Author of Global Health 101, 3rd Edition
A number of resources have recently come out that deal with intersectoral approaches to global health. Disease Control Priorities, third edition (DCP3) is a nine-volume resource “that provides up-to-date evidence on priorities that countries should consider in order to deliver Universal Health Coverage.” DCP3 recently published Volume 9 of its study, which is a summary of its major findings, plus important chapters on achieving universal health coverage and addressing intersectoral policy approaches to global health. (http://dcp-3.org/disease-control-priorities).
In November 2017, The Lancet published a companion piece to this volume: “Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition” (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32906-9/fulltext?dgcid=twitter_social_lancet).
I had the good fortune to be on the advisory committee to the editors of DCP3 and was a co-author of the Lancet piece. Largely based on the above DCP3 pieces, I prepared a bonus chapter for Global Health 101, Third Edition, which is called “Intersectoral Approaches to Enabling Better Health” and which Jones & Bartlett Learning published in December 2017. This chapter is now bundled with Global Health 101, Third Edition, and can also be purchased individually.
We recently launched the bonus chapter with a webinar on intersectoral approaches to global health. The slides I used to initiate the session are available here. I want to comment below on the main points from the webinar that might be useful to teaching and learning.
As we all know, there are few health issues that can be addressed by the ministry of health or other health agencies alone. In addition, the more one thinks about the social determinants of health and sets of linked or “syndemic” health problems, the more one realizes the importance of the ministry of health working in conjunction with other agencies to address health problems effectively, efficiently, fairly, and sustainably.
In some respects, as one webinar participant suggested, there is nothing new about the need for intersectoral approaches to enabling better health. However, the DCP3 and Lancet pieces and, I hope, my chapter, provide a more coherent framework than was previously available for thinking about issues that require an intersectoral approach. This includes considering the type of actions that might be taken; the agencies that need to be involved; and the platforms, within and outside the health sector, that are best for delivering the proposed interventions.
Unfortunately, there is no guide for how to teach our students to think coherently about the importance of intersectoral approaches. The comments from the webinar suggest that most faculty teach about the need for intersectoral approaches throughout their global health courses. They also suggest that few faculty set aside time to provide their students with a framework for understanding the need for intersectoral approaches, the types of intersectoral action required, by whom, and how these actions can best be delivered.
Most of us struggle to decide what topics we can fit into our courses and which ones we must leave out. Having thought further about how we might teach about intersectoral approaches, I would now recommend carving out some specific time, early in a course, to discuss with our students a coherent framework, like that in DCP3 and my bonus chapter, for guiding their thinking about the need for intersectoral approaches and how to put them in place.
When we discuss intersectoral approaches with our students, it will be a good time to remind them of the framework I mentioned in the webinar for moving from diagnosing issues to outlining solutions to them, to deciding when intersectoral issues are needed to address them.
- What do people get sick, disabled, and die from?
- Which people?
- Why does this happen to them?
- What have we learned can be done, at least cost, in doable, sustainable, and fair ways to address those problems?
- To what extent can the ministry of health alone address the problem? If not, what other agencies need to be involved and through what type of action?
This framework alone, however, may not be enough to help all of our students understand the place of intersectoral approaches in addressing critical health issues. This will be especially true for those students who are new to public health and global health. They are likely to have some difficulty understanding the context for determining what agencies should address key health problems and how they should do so.
Thus, I want to suggest that many of us will want to use “mini-cases” to help students understand intersectoral approaches. Some of these cases can focus on specific health problems, such as unsafe childbirth, undernutrition or obesity, or tobacco smoking . In addition, it might be best to “ground” the stories in specific countries. In each case, we could help our students work through the nature and magnitude of the issue, who is most affected, and the risk factors and social determinants that are at the root of the problem. We can then go over what actions are needed, by whom, and the place of the ministry of health and other agencies in addressing the problem.
As we go through such cases, it will also be very helpful for students to think about the types of actions that need to be taken: should they focus on fiscal or regulatory matters, information and education, or the built environment? Many of our students may also be quite naïve about the role of the ministry of finance in improving health. Thus, we may need to help our students see the place of fiscal and regulatory policies in addressing important health problems. For example, what is the role and effectiveness of taxing tobacco in reducing the uptake of tobacco smoking? What is the evidence that taxes on sugary beverages are effective and good tax instruments, for example?
The fact that issues outside the health sector have a large impact on our health is well known. With the help of some new resources, we now have an opportunity to better enable our students to think critically about these issues and how they relate to global health.
Richard Skolnik has worked over 40 years in international development and global health. After 25 years at the World Bank, he spent 8 years teaching global health at The George Washington University. He recently retired from five years at Yale University, where he taught global health courses in Yale College, the Yale School of Public Health, and the Yale School of Management. Richard is the author of Global Health 101, Third Edition.
Ms. Rachel Strodel offered valuable comments on the draft of this blog.