Knowledge Summary 11: Engage across sectors
In 1978, the International Conference on Primary Health Care in Alma-Ata called for cooperation and coordinated effort across “all related sectors and aspects of national and community development.” More than 30 years later, striving to achieve broader development goals remains essential to improving reproductive, maternal, newborn and child health (RMNCH).
Providing access to good quality services is a core component of RMNCH strategies everywhere, but a range of factors act as barriers to achieving this. Poverty, gender inequities, denial of rights, lack of education and safe drinking water, inadequate roads and transport, and poor sanitary conditions are some of them. Ministries of health cannot remove these barriers alone, so inter-sectoral collaboration is essential to achieving both coherent policies and better results.
The MDGs have achieved much. Globally, communities have come together to rally around them and have successfully raised the profile of specific issues, leading to improved funding and impact of programs. More could be achieved by exploiting the synergies that exist between sectors.
What do we know?Poverty, hunger and ill health (MDG 1)
Whilst economic growth has led to some reductions in overall poverty, this masks the inequities within countries. Moreover, sub-Saharan Africa,Western Asia and some countries in Eastern Europe will not achieve the MDG target of halving poverty. Many people have been forced into vulnerable jobs as a result of the financial crisis, and more workers now live in extreme poverty. High food prices have led to lower food intake and undernourishment. Substantial evidence over the years has pointed to the inter-relationship between poverty, inequity and ill-health. The poorest and least educated women and their children also have the worst access to quality services. For example, in Tajikistan, a weak economy and poor quality of services contributed to an increase in health care costs. As a result, pregnant women sought less care.Gender, education and health (MDGs 2 and 3)
Gender inequity exists both within and outside the health system and is intertwined with factors such as poverty, ethnicity, caste and race. In women’s daily lives, this manifests as poor access to health resources, sexual abuse and violence, including female genital mutilation. To address health inequities, it is essential to empower women and ensure that their rights and health are protected (see Knowledge Summary 9). Men play a crucial role in determining health outcomes in women. For example, negotiating condom use is difficult in many contexts due to unequal power relations.This can lead to unintended pregnancies and expose women to a higher risk of HIV infection.
The links between women’s education and RMNCH have been long established.6 Gender, education and health are inter-related with poverty. Confirming this, a recent review indicates that between 1970 and 2009, increased schooling levels amongst women (now aged 15 to 44) contributed to nearly 50% of the reduction in deaths among children under five in developing countries. However, despite major advances in primary school enrolment, girls from the poorest households are 3.5 times more likely to be out of school than girls from the richest families. Gender parity in secondary education, particularly in rural areas, is still very low in sub-Saharan Africa, South Asia and Western Asia.Safe drinking water, sanitation and health (MDG 7)
Gender, safe water, sanitation and health have many connections. For example, pregnant women are at greater risk from hookworm infestations, which can lead to low birth weight and poor growth in children. Simple measures such as hand washing among new mothers and birth attendants, during and after childbirth, are suggested to have contributed to reductions in newborn deaths in Nepal. Access to safe and clean water is improving in some rural areas, but is still a challenge in others. In urban Kenya and Zambia, for example, population growth was associated with a negative trend in access to safe drinking water and in vaccination coverage, and contributed to increased child deaths. Sanitation continues to be a major problem. In 2008, only 52% of the population in developing countries had any improved sanitation facilities, and the problem of open defecation remains. When sanitation is poor, water quality also suffers and contributes to diseases such as diarrhea, which is a leading cause of death in children under five years of age.
What works?Inter-sectoral collaboration is possible, but local contextual factors influence success
Countries like Sri Lanka,Thailand and the state of Kerala in India have successfully improved the health of women and children through a holistic approach to healthcare provision. More recent examples of inter-sectoral linkages have been reported from child nutrition programs in Bolivia, HIV/AIDS programs in Nigeria, and participatory public health schemes in Brazil. Further examples can be found in Rwanda and several other countries. However, inter-sectoral collaboration is not easy, as a review of 15 developed countries showed. Comparative lessons from Sri Lanka and Uganda provide further insights.Some interventions in other sectors can support progress in MDGs 4 and 5
Studies show that microfinance schemes can increase income levels, empower women and improve the health of mothers and children. Similarly, unconditional cash transfers, such as South Africa’s Child Support Grant, and conditional cash transfers such as Oportunidades in Mexico, have contributed to better outcomes in education and health. Reviews have shown that midday-meal schemes at schools significantly improve children’s physical and mental growth. Interventions to improve hygienic practices have included household level interventions, such as water treatment, hand washing and promotion of the use of improved toilet facilities. Although studies show that household level water treatment can contribute to better health, the evidence to support scaling-up is weak. Participatory approaches to encourage hygienic behavior and toilet use are still being tested.
It is evident that the same women and children – those who are poor, living in rural areas and less educated – are also the ones who face the greatest risks of ill-health and death. Poor health is not only a consequence of poverty and disadvantage, but also a cause.This vicious cycle can be broken by recognizing these interdependencies, and through joined-up actions and effective inter-sectoral collaboration.