INTERSECTORAL COORDINATION

Introduction:- Health is intrinsically related to development. However, the inter-linkages

between health and development were brought to the limelight at the Alma Ata conference on
Primary Health Care (PHC) in 1978. The Alma Ata conference not only gave a new impetus to
the inter- linkages between health and development but also restated the fact that `Health for All'
could not be achieved without inter-sectoral co-ordination. Intersectoral collaboration refers to
the promotion and coordination of the activities of different sectors. Health planners have often
identified agriculture, education, water and sanitation and the environment as those sectors that
can and that should collaborate in helping to reduce inequities in health. This can apply to
individuals, interest groups, administrative units or even nation states. The inter- dependence
might be caused by the fact that individual goals can only be achieved in joint actions or by the
fact that effects of individual programme’s can be anticipated that have an impact on the interests
of others.

DEFINITION-
Sectors:-

 The definition of “sectors” can be based on the policy dimension (policies and programmes affecting
certain subject areas) or on the polity dimension (actors, networks, bureaucratic structures, etc.).
 Defining sectors from a policy perspective means delimiting subject areas that are primarily affected
by a certain group of programmes and policies (environmental policy, research policy, social policy,
etc.). Regarding the polity dimension, programmes do not co-ordinate themselves, but it takes actors to
co-ordinate their activities and programmes.
Co-ordination :-
 Referring to co-ordination as a status, sectors are co-ordinated when their respective policies
and programmes show minimum redundancy (two initiatives doing the same without
considering each other), minimum incoherence (different goals and requirements), and a
minimum of untackled issues (“policy gaps”).

Intersectoral coordination:-
Intersectoral coordination is the process is about the organisational and reconcillation of
different processes and activities, which take place simultaneously or consecutively.

NEED FOR INTERSECTORAL APPROACH

 Restructuring of the health services infrastructure

 Increase of the medical and health manpower

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  Community involvement
 Government’s focus on preventive and primary health.
 Provision of free or affordable medical aid to the indigent and needy by providing appropriate
safety nets
 Exploiting the services of private medical practitioners
 Utilizing traditional and other systems of medicine
 Involvement and utilization of services of the voluntary agencies active in the health field
 Modes for financing the envisaged additional expenditure on health and
 Enlarged role for the private sector and NGO’s participation in health delivery

BENEFITS OF INTERSECTORAL COORDINATION:- The benefits expected from inter-sectoral

co-ordination are:
 to achieve goals which cannot be achieved alone.
 to increase the chance that those policy alternatives are chosen which are most likely to result in
the highest overall welfare gains.
 to help to prevent overall welfare losses because of policies that entail positive welfare effects
for individual actors, but disadvantages from an overall point of view.
 to provide legitimacy and acceptance to public policy
 to lead to more effective public policies.
 to enhanced governance knowledge, mutual learning.
 reduced risk of deadlock in decision making
 avoidance of unintended side-effects
 the prevention of implementation resistance.

 inter-sectoral co-ordination may gain from transparent and participatory procedures in terms of
more obvious legitimacy.
GENERAL PRINCIPLES :-
1.Development is basic to health
Health is closely related to development. Therefore, any action taken to promote health must be
necessarily linked to the process of development. Defining the concept of development has led to
an unending debate as there are different views . However, there are two critical variables which
most of the participants of development debate tend to consider important. They are growth, or

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production, and distribution. There are many theories and approaches on how to achieve faster
economic growth. The latest and the dominant approach seems to be the market-led economic
growth (free market). Similarly there are many views on distribution. While some argue in
favour of equitable distribution, the others emphasise distribution in proportion to one's
contribution to growth.

2.Equity-

 The principle of equity essentially follows from the previous principle. However, it must
not be considered as having a relationship with only the `distribution' aspect of
development. Equity must also be considered in terms of production.
 For example, agricultural production involves ownership and use of land, technology and
labour. Therefore, when we discuss the principle of equity in the context of health of the
people particularly the poor, who form the majority of the labour force, it is also
necessary to ask the following question- Do or can the poor have the right (at least some
if not equal) to ownership of land, technology and labour?
 The most common understanding of equity in terms of health is that "every man, woman
and child, no matter where he or she lives, has the right to enjoy good health and deserves
to have access to health care services."
 Firstly, there must be enough health care service availability.
 Secondly, whatever is available must be accessible to the poor, forgotten and the
marginalised. However, the meaning of ‘accessibility’ assumes greater importance
because there are many factors that determine access.An example is providing transport
facilities to reach the clinic or the hospital.
 There are many other factors determining accessibility. However, the most important
determining factor is the capacity or the power of the people, and the immediate factor to
be considered for building the capacity of the poor is their economic status.

3.Promoting economic capacity of the people (poor)-

Economy plays an important role in the health status of the people. It not only enables the people
to undertake preventive and curative health care measures, but it also promotes sustainability of
their health status. There are many country or community specific strategies or programmes
involved to build people's economic capacity.
Some of the key strategies are enabling the poor to have:
1. asset creation and development
2. capital formation
3. employment opportunities in the private or public sector
4. access to market avenues.

a)Asset Creation and Development

One of the major causes of poverty and its resulting impact on health is the lack of productive
assets or resources, such as land, technology and labour. There are people who do not own land,
and there are those who own land but do not have the needed technology or the labour to
cultivate the land. In such cases, it is imperative that the poor are enabled to have access to
productive assets and resources. If land distribution is not possible, the landless can be given
other assets such as milk animals, machines and forest, etc. depending on the viability. Similarly

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 people may have land but may not have the capital to work on the land or there may not any
irrigation facility. In such cases there is a need to develop the land.

b)Capital Formation
Often we come across people who have productive assests but lack capital to use their
assests(land and irrigation). Some people have the skill but do not have the capital to start an
economic activity. In such situations, they can be enabled to have access to capital in the
following way.
1. bank loans
2. credits and savings
3. matching grant
4. free or subsidised loans

c)Employment
Every effort must be made to encourage self-employment, seasonal employment, and
employment for the educated and the retired personnel in the community.

d)Marketing Linkages
In the trail of free market, the products produced in the traditional sector may not
always find a market. Efforts must be taken either to make the traditional sector
competitive or to find suitable market avenues. This is best done in the form of cooperatives.
Some of the examples are AMUL in Gujarat and Fishermen Federation in
Kanyakumari district.

MEASUREMENT OF INTRSECTORAL COORDINATION

1. Status of Inter-Sectoral Co-ordination:
According to Peters (1998) the following aspects can be used to describe/measure intersectoral
co-ordination as an end-state:
 degree of redundancy (two or more programmes / organizations aim at the same goals without
considering each other)
 degree of incoherence (two or more programmes / organizations aim at different goals or are based on
different requirements)
 degree of untackled issues (policy gaps, important issues are not on the agenda)

At a minimum level of inter-sectoral co-ordination, actors from different sectors or sectoral

decision-making structures are aware of each others’ programmes and initiatives and strive
not to duplicate efforts (no redundancy) or to interfere (no incoherence). At the other end of

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the scale redundancy, incoherence and the number of untackled issues are minimised; theoretically speaking,
they are avoided.
2 Process of Inter-Sectoral Co-ordination:
From a process perspective the following aspects characterise inter-sectoral co-ordination:
 the number of integrated sectors (one = intra-sectoral, some, ..., all sectors affected)
 the time-frame of co-ordination (short-term, medium-term, long-term)
 the reiterativeness (one-shot event, ..., open-ended iterative)
 the stage(s) of the policy cycle concerned (formulation, implementation, evaluation or the
whole cycle) the applied mode regarding the complexity of overall interaction patterns (hierarchical
direction without considering other sectors, negative co-ordination1, only some interaction in the form of
positive co-ordination2, but most as negative co-ordination, most interactions as positive co-ordination and
some as negative, positive co-ordination among all involved)
 the mode applied with regard to the exercise of power to constrain co-ordinated sectors
the degree of institutionalisation (e.g., non-legally/legally; informal/formal, amount of resources devoted to
a co-ordinating institution).
3. Inter-Sectoral Co-ordination Capacity Scale (Metcalfe 1994 and 1997)
Metcalfe (1994 and 1997) developed a “policy co-ordination scale” and subsequently “coordination
capacity scale”. The first version enumerated options for national co-ordination available to governments
involved in intergovernmental negotiations. It was meant to serve as a scale for comparing the status of co-
ordination in different countries, but strictly speaking it does not refer to the status, but to procedures of co-
ordination. Furthermore, the original applies only to governmental actors. A similar scale was developed by
Metcalfe 1997 in a comparative study of European policy co-ordination in national administrations. The
logic is that capacities for co-ordination must be built in a bottom-up process step by step. Instead of
applying a hierarchical approach based on prescription and control, it assumes rather decentralized actor
networks.
Inter-Sectoral Co-ordination Capacity Scale:Step 8
Step 8 Establishing an overall inter-sectoral strategy. This step is added for the sake of completeness, but
is unlikely to be attainable in practice.
Step 7 Establishing commonly agreed or binding priorities. Inter-sectoral agreement to common priorities
and/or centre of government lays down the main lines of policy and establishes cross-sector priorities.

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Step 6 Defining common limits by setting parameters for sectoral activities. A central organisation of an
inter-sectoral decision-making body may play a more active role by constraining the admissible range of
sectoral activity. The parameters define what sectoral actors must not do, rather than prescribing what they
should do.
Step 5 Arbitration of inter-sectoral differences. Where inter-sectoral differences cannot be resolved by the
horizontal co-ordination processes a central mechanism of an ex ante commonly agreed procedure for
arbitration is applied (e.g. state hierarchy, voting).
Step 4 Avoiding policy divergences among sectors and seeking consensus. Beyond negative co-ordination
to find out differences and prevent mutual negative effects, actors/organisations work together, e.g. in joint
committees and project teams, because they recognise their interdependence and their mutual interest in
resolving policy differences.
Step 3 Consultation with others. A two-way process. Sectors/actors inform others about what they are
doing, they consult others in the process of formulating their own policies, or positions.
Step 2 Information exchange among sectors. Sectors/actors keep each other up to date about arising issues
and how they propose to act in their own areas. Reliable and accepted channels of regular communication
must exist.
Step 1 Sectors/actors manage independently within their domain/jurisdiction. Each sector retains
autonomy within its own policy domain.

Steps 1 to 8 represent levels of increasing capacities for inter-sectoral co-ordination. All parties share
responsibility for co-ordination. The role left to the central co-ordinator differs from step to step. Much co-
ordination takes place without a co-ordinator .
1. The goal of “negative co-ordination” is to ensure that any new initiative of a sector or a ministry in charge
will not interfere with policies and interests of others. In terms of welfare theory, negative co-ordination is an
attempt to avoid negative externalities and to assure that new policies will be Pareto-superior to the status quo.
Procedurally, negative co-ordination typically implies bilateral interactions between the unit in charge and the
others
who might be affected (Scharpf 1993,).
2. “Positive co-ordination” is an attempt to explore and utilize all joint strategy options of the actors
involved. It strives to maximize aggregate welfare gains. Procedurally, positive co-ordination implies
multilateral interactions (ibid.).

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3. Absolute top-down co-ordination depends on a sector’s possession and exercise of power in relation to
other sectors. Typically it involves the imposition of binding frameworks, which constrain the actions of the
sectors to be co-ordinated. Binding sectoral action plans define operational targets and timetables for reaching
them. In addition, effective reporting and review procedures are implemented to monitor progress.
4. On the other end, bottom-up approaches are based on exercising influence by raising awareness and
guidance rather than by the application of power. Co-ordinated sectors remain free to develop their
programmes according to their sectoral preferences. Key features of often incremental bottom-up co-
ordination processes are procedures which establish continuous information and interaction among the
sectors.

SECTORS CRUCIAL FOR HEALTH’S DEVELOPMEMNT:

The scholars, the policy makers and the development functionaries promoting an inter-sectoral approach to
health tend to consider seriously three major sectors that are crucial for health and development. They are:

Agriculture

Environment

Education

HEALTH AND AGRICULTURE

More than two thirds of the people in developing countries depend entirely on agriculture for their livelihood.
Some of the major factors that determine people's health are agricultural policies and products. Most of the
poor spend more time in agriculture. Most of their income is spent on food, which basically comes from the
agricultural sector. Some of the factors of agriculture that have direct influence on the health of the people are:

1. adequate farm income

2. income from agricultural labor

3. enough food (energy) for agricultural work

4. nutritional value of the food eaten

5. health hazards of agricultural technology

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 Impact of Agriculture on Health:

The following factors of agriculture affect health of the people, both positively and negatively. While some
factors affect people’s health directly, the others have an indirect impact.

1. Policies:

Food crops vs cash crops

Shift in consumption (locally grown food vs meal processed in cities)
Investment (productive regions vs poor regions)

2. Land fertility

3. Crops with harmful effects (dangerous to health) – e.g. health of farm labourers

4. Food with direct health hazards (toxic substances)

5. Agricultural products with major health hazards (tobacco and narcotics)

6. Equity in accessibility to food

HEALTH AND ENVIRONMENT

Environment have both the direct and indirect impact of environment on health.

 The indirect effect can be assessed from the nexus (intersection) between

i) poverty and environment and ii) population and environment.

 The nexus between the major components of environment -- i.e. land, air and water and health reveals
the direct impact on health.

Indirect Effect:

1. Poverty and Environment

There are two views on the nexus between poverty and environment. According to the first view, the
excruciating poverty of the rural people forces them to encroach the forest reserves for their livelihood. As a

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result there is deforestation, which further leads to fall in total rain fall and soil erosion, which adversely
affect farm production. A faster rate of decrease in farm production further accelerates poverty, thus leading
to poor health status. Therefore preservation of forest resources is advocated strongly for the better health,
particularly in the rural areas.. On the contrary, according to the second view, the declining environmental
resources such as forests are mainly the result of uncontrolled rate of growth and disparity in the consumption
of resources between the rich and the poor. It has been estimated that every thousand babies born in the
developed industrialized world consume three to four times of most of the earth's resources as 9000 born in
the developing world (Luis Indian, "Brundtland Commission Urges New Global Partnership,"

2. Population and Environment

It is true that the faster rate of population growth in the developing countries is the major cause of depletion of
natural resources. However, this is not the only reason. Besides the reasons mentioned in the previous section
on the nexus between poverty and environment, the other factor used to counter this view is the extremely
skewed distribution of resources. In the developing countries, the landless agricultural laborers form the
majority population. Lacking access to productive resources such

as land, they tend to depend on the forest resources for their existence.

Direct Method:

1. Water, Air, Land and Health

It has been argued that the health of the poor is affected by dirty water, inadequate sanitation, air pollution,
and land degradation. It is estimated that in poor countries:

a. Diarrhoeal diseases resulting from contaminated water kill over 3 million children per annum and cause
about 900 million cases of illness each year.

b. Indoor air pollution from burning wood, charcoal or animal dung endangers the health of 400--700 million
people world wide.

c. Dust and soot in city air causes 300,000--700,000 premature deaths per annum.

d. Soil erosion can cause annual economic losses ranging from 0.5 % to 1.5 % of GNP.

e. Twenty-five per cent of all irrigated land suffers from salination.

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f. Tropical forests, the primary source of livelihood for about 140 million people are being lost at the rate of
0.9 % per year. (Mukherjee, 1993.)

Mining of the earth, nuclear testing, mismanagement of radio-active wastes, dismantling of nuclear weapons,
tragedies such as Bhopal caused by Union Carbide (killing in one night 2000 people and permanently
disabling 200,000 women, men and children), and wars are some of the environmental hazards which directly
lead to dangerous health problems.

The following statement may further help us to understand the nexus between environment and health. "If any
man is rich and does give help to one who stands in need, he gives the poor man what was already his. The
earth was made for all, not just for the rich". Pope Paul IV.

HEALTH AND EDUCATION

The inter-linkages between education and health are well established. It has been proved that growth in
literacy rates, particularly among women, has produced a positive impact on health. In some countries, states
(Kerala in India) and communities, the fall in mortality, morbidity and birth rates is mostly due to the level of
education and literacy than to mere economic growth. The positive impact of education on health is the result
of improvement in personal and public hygiene, life style, environmental sanitation, appropriate nutrition, and
better understanding and positive attitudes towards preventive, curative and promotive care. However, it has
been argued that the nexus between health and education is "to be understood in the wider context of local
culture, with its structures of knowledge concerning health.” (WHO, 1986.) This concern necessitates a
deeper understanding of the inter-linkages between education, knowledge and health. It has been said that "to
know (knowledge) is to transform reality.” Certainly education and literacy can play a major role to make
health care simple and effective. Raising the literacy and educational levels of children and adults, mainly the
women, has proved to be more effective at decreasing morbidity and mortality rates than building hospitals
for specialised curative care, mostly for the rich.
INTERSECTORAL SECTORAL IN PHC AND NRHM-

 Intersectoral coordination and convergence of programme - The linkage between health

and development has been amply demonstrated globally. Health development is increasingly
becoming part of a strategy aiming to satisfied the basic needs of of population by giving the
poor access to resources and economic opportunities, raising educational standards,distribution
of food, improving status of women,improving nuritional status of individuals. GOI is commited
to achieve intersectoral coordination and convergence at multiple levels in following ways-

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 a. Convergence with different health related sectors- common district health
society is created under NRHM to promote the convergence within the health `department of
various different diseases related activities. The indicators of health depends as much on drinking
water, female literacy, nutrition,early childhood development ,sanitation,women’s empowerment
etc as they do on hospitals and functional health systems.

b. Convergence with indian system of medicine- the officially recognised codified

traditional medical system are ayurveda, yoga, naturopathy, siddha, and unani.homeopathy is not
a traditional medical system are but enjoys equal status and is assimilated in the country’s health
delivery network.there has been phenomenal growth of traditional medicine sector over the year.
Starting from an unregulating sector at the time of country’s independence a large number of
steps have been taken to support and strengthen programmes that could facilities tapping the
potential or traditional medicine system for benefits of masses and global health care.

c. Coordination with rural medical practitioners- there is a large pool of formal or

informal qualified rural health practitioners(RHP’s) who meet the day to day health care needs of
people in 6 lakh villages. In the 11th five year plan, it is proposed to enlist their services for many
tasks including1`1`` delivery of non-clinical methods of contraception and reffering the clinical
cases to the PHC’s.

d. Coordination with non- governmental and civil organisations- government of

india envisages collaboration with NGO’s and civil organisations particularly to supplement the
role to that of government health care delivery in addition to health education and awareness
programmes.

e. Public private partnership-Private sectors health services range from those provided
by large corporate hospitals. Smaller hospitals/nursing homes to clinics dispensaries run by
qualified personnel and services provided by unequalified practitioners

BARRIERS OF INTERSECTORAL COORDINATION

In practices and principles of health, health planners should be aware of the potential of health
advancement and community development through intersectoral collaboration. However , it may
well be best if progress is taken in measured and careful steps. Impatient and unplanned pursuit
of intersectoral coordination may well yeild an opposite result, a more structured and strategic
approch is recommanded as will invariably mean greater education,political support for
intersectoral support at national,regional and local levels of health and development activity.
This may not be an easy task. Most of the in disturances of the intersectoral agencies is lack of
coordination and communications between agencies.
Traditional barriers to coorination such as sectoral defensiveness may mean
that mechanisms for intersectoral coordination need to be equipped with certain authorities. This
may include addressing national decisions makers at the most senoir levek of government who
could then direct that sectoral approches reflects the desired process and content.

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 There are many factors such as science, commerence and social forces
which have moulded the health system. Health planners and decision makers will have to be
aware of this fact when considering linkages between social factors and health sectors.

ACTIONS FOR INTERSECTORAL COORDINATION:-

There are many strategies developed to follow an integrated and holistic view of Primary Health Care.
Though the strategies envisaged are at two evels, i.e. macro (government interventions) and micro
(community) levels. Later is effective.The micro level strategies are broadly categorised into four, they are:

1. asset creation

2. providing needed capital

3. employment generation

4. establishing marketing linkages

1. Asset Creation and Development

One of the major causes of poverty and its resulting impact on health is the lack of productive assets or
resources, such as land, technology and labour. There are people who do not own land, and there are those
who own land but do not have the needed technology or the labour to cultivate the land. In such cases, it is
imperative that the poor are enabled to have access to productive assets and resources. If land distribution is
not possible, the landless can be given other assets such as milk animals, machines and forest, etc. depending
on the viability. Similarly people may have land but may not have the capital to work on the land or there may
not any irrigation facility. In such cases there is a need to develop the land.

2. Capital Formation

Often we come across people who have productive assets but lack capital to use their assets, (land and
irrigation). Some people have the skill but do not have the capital to start an economic activity. In such
situations, they can be enabled to have access to capital in the following way.

 bank loans

 credits and savings

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 matching grant

 free or subsidized loans

3. Employment

Every effort must be made to encourage self-employment, seasonal employment, and employment for the
educated and the retired personnel in the community.4. Marketing Linkages

In the trail of free market, the products produced in the traditional sector may not always find a market.
Efforts must be taken either to make the traditional sector competitive or to find suitable market avenues. This
is best done in the form of cooperatives. Some of the examples are AMUL in Gujarat and Fishermen
Federation in Kanyakumari district.

REFERENCES:-
- Gulani k.k. community health nursing principles and practices.1st ed;2005.kumar
publishing house:Pp-38.
- Kumari neelam.essentials of community health nursing.1st ed;2011.pv pyblisher:Pp-
13-18
- Clement I. Basic concepts in community health nursing. 2nd edition. New Delhi: Jaypee
Brothers medical publisher; 2009. pp 142-148.
- Metcalfe, L. 1994. International Policy Co-ordination and Public Management
Reform. In: International Review of Administrative Sciences. London, Thousand
Oaks and New Delhi, Sage, Vol. 60, pp. 271-290.

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