As Non-Communicable Disease (NCD) campaigners gear up for the 3rd UN High Level Meeting on NCDs later this month – with the highest ever turnout of global leaders expected to be in attendance – we have been challenging ourselves and our partners to make sense of the rhetoric around ‘multi-stakeholder collaboration’ and ‘multi-sector working’. In seeking to identify new approaches to NCD care with the potential to fix over-stretched health systems, we ask what kinds of collaboration really have the potential to make an impact in resource-poor settings globally.
It is certainly not a new idea that multiple sectors working together can achieve more than any single organisation working alone[i]. Multi-sector nutrition plans were developed in the 1970s, with their sudden popularity linked to a number of underlying principles which today are still widely held as good practice standards by nutrition professionals. Interestingly, one of the underlying principles emerging from this early work was that malnutrition was seen for the first time as a development problem, as opposed to a disease to be addressed only by medical practitioners.[ii]
Causes of more recent growth in partnership approaches are varied. They include the success of large global initiatives such as the RBM Partnership to End Malaria, as well as the launch of the Sustainable Development Goals in 2015, which set out, for the first time an integrated agenda for the world’s development[iii]. Cross-sector partnerships are explicitly identified as central to the ‘means of implementation’ of Agenda 2030[iv].
There is also some recognition that operating in silos – while it has its advantages in terms of clarity of funding and control – can be an ineffective and even counterproductive way to tackle complex development problems[v]. There are silos between sectors as well as within sectors. For example, the effectiveness of vertical programming in health is limited if interlinkages between different diseases are not explicitly considered. People who are supported – through very significant public health investments – to live with HIV may end up dying from preventable conditions such as heart disease and diabetes due to a lack of integrated approaches[vi].
Multi-sectoral approaches to NCDs
Within this proliferating field, and amidst the significant hype, clear conclusions about effectiveness and impact of multi-sector actions are not easily drawn. Yet the case for multi-sectoral approaches can be made very simply: tackling NCDs, as a multi-dimensional or ‘wicked’[vii] problem, requires a multi-dimensional solution.
For example, within healthcare, screening without access to care can be unethical whilst training healthcare workers in NCD management will be less effective if there is nowhere to refer complex cases, or no availability of lab tests or medicines. And beyond healthcare, wider economic, social and cultural issues also need to be considered. Family doctors may be trained but the training is wasted if there are no jobs through which they can contribute their knowledge. And if opportunities for economic growth and savings are not available to households, people are unlikely to prioritise paying for care while still symptomless, which may lead to distress borrowing and sale of assets at the onset of a health crisis. Meanwhile low levels of health-seeking behaviour can also be attributed to education levels, stigma and cultural beliefs associated with chronic diseases, particularly mental health.
In this vicious cycle, equitable access to quality healthcare itself in turn has a significant bearing on household income and broader socio-economic measures. Put simply, people who are healthy – or whose chronic condition is well-controlled – are able to work, educate their children and provide adequate nutrition and protection for their families. In many ways these linkages are obvious. What is less obvious is whether and how organisations that normally address these issues in isolation should or might collaborate to achieve more effective outcomes overall.
The opportunities for multi-sector action
Our conversations with a diverse range of partners over the past two years give us reason for optimism. The clear opportunities afforded to other sectors investing in healthcare are in essence cost avoidance and value creation. Significant costs and limited programme effectiveness result when health is ignored in decision-making processes, such as worker days lost due to ill-health. This should be of particular interest to employers and insurers. Meanwhile, new opportunities to add value are available when health is strategically factored into decision-making processes, such as innovation in programmes, goods and services. NGOs, (social) businesses and governments are increasingly conscious of the potential gains of integrated action.
Understanding of the economic case for tackling NCDs has recently received a boost from the Lancet’s Taskforce on NCDs and Economics, under the aegis of the WHO Independent High-Level Commission on NCDs. This has identified the ‘tight-knit connection’ between economic growth and controlling NCDs. The five Taskforce papers show that poverty drives and is driven by NCDs, but that financial protection from high medical costs can break this cycle; price policies and taxation are effective means to reduce NCD risk factors, such as tobacco and unhealthy diet, and can reduce inequalities; and that investment in NCD control results in increased economic growth[viii].
When NCD prevention and care is seen as a development challenge rather than purely a medical challenge, it can open up significant new ways of working. The community development sector operating in poor areas of the USA has already recognised the huge opportunity of partnering with the health sector[ix], and the nutrition sector is exploring links between undernutrition, overnutrition and NCDs, particularly obesity[x]. Other development actors are likely to follow suit with their own approaches to health, particularly in terms of linkages between NCDs and other sustainable development goals under Agenda 2030.
There are several examples of how a narrow focus has gradually widened to encompass multiple sectors. Where development agencies may once have focussed on water, for example, the field expanded to water and sanitation, then to water, sanitation and hygiene (WASH). This expansion of approach stemmed from a recognition that gains in accessing clean water would not result in long-term improvements unless accompanied by health promotion and behaviour change campaigns. A similar evolution has also taken place in another direction around the ‘food-water-energy’ nexus[xi]. Meanwhile in the private sector, companies have identified how responding to the health-related SDGs represents an estimated $1.8 trillion business opportunity, and are creating new goods and services in return. Clean cook stoves are just one example; shifting 2.7 billion people to modern cooking fuels and improved stoves could avert up to 2.6million premature deaths from COPD annually, particularly women and children[xii].
It is clear that organisations interested in testing multi-sector approaches can find many opportunities for innovation and broader benefits through partnering with the healthcare sector. As well as such hard returns that are available – productivity improvements and cost avoidance opportunities – there is another more compelling reason for sectors beyond health to work with this sector. At its best, the healthcare sector brings a depth of compassion and an instinct for protecting human life. If these values became the norm across sectors, rather than the exception, NCD trends would quickly be reversed.
The challenge for us all now is to be ambitious, creative and transparent in exploring existing synergies and disrupting broken systems as we seek new ways to tackle the fast-growing burden of NCDs.
PCI is co-hosting an event at C3 Collaborating for Health on Thursday 4th October to debate these issues alongside invited panellists. A paper outlining the evidence for multi-sector partnerships will be shared. Register for the event here.
With thanks to Dave Prescott, a partnership specialist who conducted a series of interviews and reviewed a wide range of soft/grey literature on this theme during the early part of 2018, in order to prepare an internal report for PCI. Many of the insights in this blog arose from this rich body of work.