Noncommunicable diseases (NCD) are a major public health problem undermining social and economic development throughout the world, particularly for low and middle income countries. The WHO also estimates that 74% (41 Million) of the global deaths and 86% of premature deaths are due to NCD in occurred in low- and middle-income countries and, if “business as usual” continues, the total annual number of deaths from NCD will increase to 55 million by 2030. In Botswana, NCDs are responsible for over 37% of total deaths. As an effort to respond to the devastating effects of the silent epidemic, in 2011 the United Nations Political Declaration on the Prevention and Control of NCD recognized prevention must be the cornerstone of the global response to NCD and acknowledged the need for a multi-sectoral approach including all government levels to comprehensively and decisively address risk factors and underlying health determinants. Almost four years ago, HE Mokgweetsi Masisi launched the Botswana National Strategic Framework on NCDs and risk factors, the framework emphasis on the multi-sectoral action (MSA) in the response leveraging against the response to HIV/AIDS. The Framework was to run from 2019 to 2023, what is that has been done to respond to NCDs and risk factors? Is it impactful as it was in the response to HIV/AIDS? If not why?
According to the WHO “ Best Buys” and Health in All (HiAP), engaging in multi-sectoral actions for health is done using three primary approaches, firstly inter-sectoral action, secondly healthy public policy, and lastly health in all policies. Inter-sectoral action, proposed by the 1978 Alma Ata Declaration involves efforts by the health sector to collaborate with other public policy sectors to improve health outcomes, the Ottawa Charter which introduced healthy public policy, called for accountability for health impact. The aim of HiAP is to bring diverse sectors together to find shared solutions, it focuses on identifying win-win such that policy measures contribute not only to improved health outcomes but also to outcomes desired by other sectors, such as education, academia, environment, Investment, agriculture, and transportation etc. As such, HiAP has been suggested as an approach to addressing ‘wicked’ problems; that is, policy problems that are complex or intractable, where cause and effect have not been clear, and may require solutions of an interdependent effort. As the National Strategic Framework on NCDs and risk factors was to run from 2019 to 2023 what is it that has been done thus by National AIDS and Health Promotion Agency (AHPA)?
HiAP is a relatively new concept and policy practice that attempts to incorporate consideration into the policy decision-making process of how public policies and programs affect community health and well-being. It represents a way of working across sectors that aims to find solutions for complex, interrelated, and persistent problems. The literature indicates that with the global epidemic in NCDs, HiAP offers a potential approach and a pathway to secure coordinated action on social determinants of health that relate to NCDs and result in health inequalities. Promising examples can be seen globally for action on both specific NCD risk factors as well as in a more systemic approach to policy decision making.
According to various literature sources the term Health in All Policies (HiAP) was coined in the late 1990s, although its roots can be traced back to the early history of public health when the importance of social determinants of health was recognized by the Greeks and Romans. Furthermore, the literature indicates that during the Finnish EU presidency in 2006, this approach to policy making was explored through a resolution that called for member states to undertake health impact assessment (HIA) of major policy initiatives, with specific attention to policy impact on equity.
HiAP is a collaborative approach to improving the health of all people by incorporating health considerations into policy decision making across sectors, (Rudolph et al. 2013). From the public policy perspective, it has variously been linked to other terms such as joined-up government, horizontal governance, policy coherence, partnerships, and whole-of-government, as well as whole-of-society approach. From a public health perspective, it also reflects the one health approach, which requires close cooperation between the other sectors. From a health-promotion perspective, the HiAP concept and practice builds on earlier and closely related concepts of healthy public policy and intersectoral action.
HiAP has been applied to a myriad of public health concerns to address the non-health sector influences on health outcomes. The importance of public policy measures to control NCD risk factors has been well established and forms the basis of the WHO’s recommended “NCD’s Best Buys” (WHO 2011a). The most advanced practices are in tobacco control, with lessons increasingly applied to alcohol, nutrition, physical activity, and mental health. Public policy emerges from the interplay between institutions, interests, and ideas. Recently there was drama at Parliament with the opposition MP Hon Ignatius Moswaane kicked out from parly after he submitted claims that diabetes patients are being sentenced to death row as there is shortage of drugs. The fundamental question is what is that is leading to such state of affairs if indeed true?
Health policy is a subset of public policy and can be understood as the courses of action (and inaction) that affect the sets of institutions, organizations, services, and funding arrangements of the health system. Health policy determinants are the outcomes of actions within and between sectors, at the local, regional, national, and global levels, that influence the social and economic landscape, which in turn influences the population’s health and wellbeing. The study of these determinants requires a multidisciplinary approach to public policy making and therefore aims to explain interactions between institutions, interests, and ideas in the policy process.
As public policy measures intervene at the population level, their impact is bigger than individual-level interventions. When targeted, they can also be effective in reducing social and health inequities through action on broader social determinants of health. While the concept of intersectoral action for health gain is well recognized, the challenge for many governments is how best to operationalize it. What is of paramount importance is to make an assessment on what is that has been done by the government of Botswana and NAHPA since the launch of the national strategic framework on NCDs and risk factors.
Some of the practical challenges on adopting the HiAP initiative as mentioned in the literature includes lack of simple solutions, limited understanding of causal pathways, lack of available stratified and small area data, length of time needed to achieve results, need for multiple sectors to work in concert, levers at different levels of government, and competing policy agendas. Could this be the case in Botswana?
Nonetheless, the experiences around the world to date identify a variety of tools being used to implement the HiAP approach. Firstly, governance structures (such as inter-ministerial and interdepartmental committees, cross-sector action teams, partnership forums, integrated budgets and accounting), secondly shared activities (joint workforce development, information and evaluation systems, community consultations, integrated reporting). Lastly the analytical tools (health lens, health impact assessment). Is this what is playing out with respect to the implementation process on the response to NCDs and risk factors in the country or is business as usual.
Governance structures provide a practical mechanism and reflect the mandate for joint work across sectors of government, and for engagement with stakeholders in the policy process. Governance provides mechanisms for scrutiny on the work done, the campaigns carried out if at all any and how such have carried out. There is need for accountability with the development of stakeholder mapping, clear cut educational campaigns tools done in line with the National Strategic Framework and WHO “Best Buys”. Such structures can be established at the political level, the bureaucratic level, and through partnership arrangements with non-state actors.
Although HiAP is a relatively new development in public policy, there are experiences of HiAP in both developed and developing countries, and these examples are applied to specific issues of relevance to NCDs and to a systems approach to policy development. They are also applied at national and subnational levels. The most notable example of an HiAP approach applied internationally for NCD prevention and control is the Framework Convention on Tobacco Control (FCTC), which is being implemented in Botswana. Increasingly, HiAP is being adopted to address other NCD risk factors such as alcohol use and obesity (for example, food, physical activity, active transport).
For the policies and programs that focus on key NCD risk factors, whether at the national or subnational level, there is a general approach of adopting multilevel and multi-sectoral interventions, consistent with the Ottawa Charter for Health Promotion (WHO 1986). Being clear about possible effective action may be a prelude to establishing a multisectoral structure or plan. The WHO’s Best Buys is a useful starting point for assessing a realistic entry point for HiAP. The multisectoral structure, if it is result-oriented, is likely to be dependent on priority areas for action. The assignment of responsibilities should be clear, with clear lines of accountability leveraging in the response to HIV/AIDS without reinventing the wheel.
*Thabo Lucas Seleke, Doctoral Candidate, Global Health Policy, LSHTM
