Multisectoral and intersectoral action for

improved health and well-being for all:

mapping of the WHO European Region
Governance for a sustainable future:
improving health and well-being for all

Final Report
Multisectoral and intersectoral action for
improved health and well-being for all:
mapping of the WHO European Region
Governance for a sustainable future:
improving health and well-being for all

Final Report
Abstract
Achieving the 2030 Agenda for Sustainable Development, and the strategic objectives of Health 2020, requires
an innovative and new model of governance. A mapping exercise was undertaken by the Governance for Health
Programme to identify instances of multisectoral and intersectoral action for improved health and well-being for all and
to share best practices for multisectoral and intersectoral health and well-being policy development and implementation
across the WHO European Region. Case stories, or narratives of good practice, detailing successful multisectoral and
intersectoral initiatives were collected through consultations in 36 Member States of the WHO European Region. The
case stories are collected and analysed in this report.

Keywords
intersectoral action
health
wellbeing
governance
coherence

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Document number: WHO/EURO:2018-2667-42423-58849

© World Health Organization 2018

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Edited by Jane Ward

Book design by Marta Pasqualato
 Multisectoral and intersectoral action for improved health and well-being for all:
mapping of the WHO European Region

Contents

Foreword.................................................................................................................. vii
Acknowledgements................................................................................................ viii
Abbreviations........................................................................................................... ix
Executive summary................................................................................................... x
Summary of the main findings........................................................................................ x
Initiators and triggers.......................................................................................................... x
Policy areas....................................................................................................................... xi
Implementation actions...................................................................................................... xi
Facilitators.......................................................................................................................... xi
Challenges and barriers.....................................................................................................xii
Recommendations.......................................................................................................... xii
Summary of main conclusions..................................................................................... xiii
Introduction................................................................................................................ 1
Multisectoral and intersectoral action for health and well-being: a long-standing
consensus......................................................................................................................... 1
Current approaches to multisectoral and intersectoral action for health and well-
being and well-being........................................................................................................ 2
Overview of the report...................................................................................................... 4
Methodology.............................................................................................................. 5
Case selection and data collection.................................................................................5
Findings...................................................................................................................... 9
Initiating multisectoral and intersectoral action for health and well-being................. 9
Why multisectoral and intersectoral action?.......................................................................9
Triggers.............................................................................................................................10
Scope and focus of multisectoral and intersectoral policies for health and well-
being................................................................................................................................ 11
Policy areas...................................................................................................................... 11
National or regional health policies................................................................................... 11
Prevention and control of NCDs....................................................................................... 13
Health promotion in schools.............................................................................................. 13
Gender, equity, and human rights..................................................................................... 14

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Implementation of multisectoral and intersectoral policies for health and well-

being................................................................................................................................16
Forms of multisectoral and intersectoral action................................................................16
Governance coherence..................................................................................................... 17
Enabling and facilitating factors........................................................................................ 18
Political will and good governance.................................................................................... 18
Mandate............................................................................................................................19
Resources.........................................................................................................................19
Data and evidence............................................................................................................ 20
Multisectoral and intersectoral capacity............................................................................20
Multisectoral and intersectoral collaboration.....................................................................20
Civil society and the media............................................................................................... 22
Other contextual factors.................................................................................................... 22
Challenges and barriers.................................................................................................... 23
Overarching findings, insights and lessons learned.................................................. 23
Strengthening implementation by building multisectoral and intersectoral capacity......... 24
Mobilization of resources.................................................................................................. 24
Impact and lessons learned........................................................................................... 25
Case story summaries............................................................................................ 27
1. Albania: Introducing a smoking ban.........................................................................27
2. Andorra: Tackling childhood obesity and sedentary lifestyle using a
multisectoral approach: the Nereu programme........................................................... 27
3. Armenia: National campaign to raise public awareness of AMR........................... 29
4. Austria: Austrian health targets.................................................................................30
5. Azerbaijan: National Strategy on NCD Prevention and Control 2013–2020.......... 31
6. Belgium: Response to Ebola crisis...........................................................................32
7. Bosnia and Herzegovina: Mental health services at community level.................. 34
8. Croatia: Intersectoral Committee on Environment and Health.............................. 35
9. Cyprus: National Strategy and Action Plan to Fight Sexual Abuse, Exploitation of
Children and Child Pornography 2016–2019................................................................36
10. Czech Republic: Action plans for implementation of Health 2020: National
Strategy for Health Protection, Promotion and Disease Prevention......................... 37
11. Denmark: Intersectoral action for health at the municipal level: implementing
health promotion packages........................................................................................... 38
12. Estonia: National Health Plan 2009–2020...............................................................40
13. Finland: Health in all policies (approach)...............................................................41

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14. France: Improving the health of school-age children........................................... 42

15. Georgia: Tobacco control: whole-of-government approach................................. 43
16. Germany: AMR strategies (DART 1 and 2).............................................................44
17. Hungary: Comprehensive health promotion in schools....................................... 45
18. Iceland: Establishment of a Ministerial Council on Public Health: a public
health milestone for Iceland.......................................................................................... 46
19. Ireland: Healthy Ireland............................................................................................ 48
20. Israel: A government decision to promote a healthy and active lifestyle............ 49
21. Latvia: Advisory Council for Maternal and Child Health: intersectoral action
with civil society............................................................................................................. 50
22. Lithuania: State Health Affairs Commission.......................................................... 51
23. Luxembourg: Get moving and eat healthier! A decade of intersectoral action to
reduce obesity in Luxembourg...................................................................................... 52
24. Malta: A whole-of-school approach to healthy lifestyles: healthy eating and
physical activity.............................................................................................................. 53
25. Monaco: Intersectoral collaboration to test an alert system for arrival of highly
infectious diseases by sea............................................................................................. 55
26. Montenegro: Intersectoral action to reduce salt intake in Montenegro.............. 56
27. Norway: National system for the follow-up of public health policies: a common
cross-sectoral reporting system................................................................................... 58
28. Romania: Integrated community-based services for health and well-being....... 59
29. Republic of Moldova: National Reproductive Health Strategy 2005–2015.......... 60
30. San Marino: EXPO 2015: an opportunity to highlight the importance of nutrition
and sustainable agriculture in school settings............................................................ 61
31. Serbia: Implementation of the Protocol on Water and Health.............................. 62
32. Slovenia: Development of the Active and Healthy Ageing Strategy.................... 63
33. Spain: National Strategy on Patient Safety............................................................ 65
34. Sweden: Promoting social sustainability through intersectoral action at the
local and regional level.................................................................................................. 66
35. Switzerland: Swiss Health Foreign Policy..............................................................67
36. The former Yugoslav Republic of Macedonia: Government Committee on
Environment and Health................................................................................................. 68

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Conclusions............................................................................................................. 70
Promoting transformative change in line with the 2030 Agenda............................... 70
References............................................................................................................... 73
Annex 1. Template for case stories on multisectoral and intersectoral action
for health and well-being (interview guide)........................................................... 75

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Foreword
Multisectoral and intersectoral action is crucial for health and well-being. Without working
beyond the health sector, we will simply be unable to address the complex challenges that we
face in our efforts to improve health and well-being, and reduce inequalities and inequities.

There is a significant legacy of multisectoral and intersectoral action in the WHO European
Region. Knowledge and experience in the Region on the subject is broad and increasing,
but in order to support change, we need to increase our efforts towards documenting,
understanding, and drawing lessons from new and old practices and initiatives.

WHO European Member States are committed to the goals of the United Nations 2030
Agenda for Sustainable Development, and to the ongoing implementation of Health 2020, the
European policy and framework for health and well-being. They recognize that this requires
developing good policies and actions across all sectors that impact on health, well-being, and
health equity, and that this must be done by developing new models of governance that focus
on partnership and the scaling up of multisectoral and intersectoral working.

In 2015, WHO European Member States adopted the decision at the 65th session of the
Regional Committee for Europe on Promoting intersectoral action for health and well-
being in the WHO European Region: health is a political choice. They requested support
in the development and implementation of multisectoral and intersectoral action. The WHO
Regional Office for Europe has committed to providing this support through documenting,
understanding and drawing lessons from new and existing practices and initiatives.

This mapping exercise is an important contribution to the knowledge and understanding

of governance for health and well-being; it provides lessons and evidence from practice
in the process of the implementation Health 2020, in the context of WHO’s contribution
to the achievement of the 2030 Agenda and the 17 Sustainable Development Goals, and
in the broader work of WHO on governance for health and well-being. Multisectoral and
intersectoral action for health and well-being requires new and improved approaches to
governance, and the mapping will inform the WHO European Region Governance for Health
Programme in the development of systematic approaches to strengthening governance for
health and well-being.

Monika Kosinska
Programme Manager, Governance for Health
Regional Focal Point, WHO European Healthy Cities Network
Division of Policy and Governance for Health and Well-being
WHO Regional Office for Europe

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Acknowledgements
This mapping exercise was undertaken by the Governance for Health Programme, Division
of Policy and Governance for Health and Well-being, WHO Regional Office for Europe. The
report was prepared by WHO consultant Adam Tiliouine.

The exercise was supported by an external project team comprising the following: Juha
Mikkonen, Tatjana Buzeti, David Gzirishvili, Neda Milevska-Kostova, Leda Nemer, Riikka
Rantala, and Tamsin Rose.

WHO would like to thank the following staff of the Division of Policy and Governance for
Health and Well-being who contributed to the process of the mapping exercise: Piroska
Östlin (Divisional Director), Agis Tsouros, Christine Brown, Snezhana Chichevalieva and
Francesco Zambon.

The following Member States contributed case stories to the mapping exercise, and WHO
would like to thank them for their contributions: Albania, Andorra, Armenia, Austria, Azerbaijan,
Belgium, Bosnia and Herzegovina, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland, France, Georgia, Germany, Hungary, Iceland, Ireland, Israel, Latvia, Lithuania,
Luxembourg, Malta, Monaco, Montenegro, Norway, Romania, Republic of Moldova, Republic
of Serbia, San Marino, Slovenia, Spain, Sweden, Switzerland and the former Yugoslav
Republic of Macedonia.

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Abbreviations
AMR antimicrobial resistance

DART German antimicrobial resistance strategy (Deutsche Antibiotika-Resistenzstrategie)

EU European Union

HiAP health in all policies

NCDs noncommunicable diseases

NGO nongovernmental organization

SDG Sustainable Development Goal

SEEHN South-eastern Europe Health Network

SCI Small Countries Initiative

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Executive summary
Many of our most pressing health and well-being problems and challenges cannot be solved
without addressing their underlying determinants, many of which lie beyond the health sector
and require engagement with sectors beyond health. As recognized in the United Nations 2030
Agenda for Sustainable Development (2030 Agenda) and in Health 2020, the European health
policy framework, engaging sectors beyond health requires new and improved approaches
to governance for health and well-being. In particular, a focus on whole system approaches,
such as whole-of-government, whole-of-society, whole-of-city, health in all policies (HiAP)
and other multisectoral and intersectoral approaches.

These approaches not only help to address health and well-being challenges that transcend
traditional sectoral boundaries but also promote good governance for health and well-being
by building accountability across sectors that impact health and well-being, encouraging
broader participation in the policy process, enhancing policy coherence and strengthening
collaborations and partnerships to improve health and well-being.

A two-part mapping exercise was undertaken across the WHO European Region by the
Governance for Health programme to identify examples of good practice of multisectoral
and intersectoral action for health and well-being, and to identify lessons learned for health
policy development and implementation. Part One consisted of an internal mapping within
the WHO European Office. Part Two was external, with case stories or narratives of good
practice, detailing multisectoral and intersectoral initiatives drafted through consultations in
36 Member States of the WHO European Region. This report summarizes the findings of Part
Two the mapping exercise.

Summary of the main findings

This analysis focuses on four key areas: (i) why and how multisectoral and intersectoral action
was initiated (initiators and triggers); (ii) the focus and nature of multisectoral and intersectoral
action across the case stories (policy areas); (iii) how multisectoral and intersectoral action
was implemented in each Member State (implementation actions); and (iv) the impact and
lessons learned (Facilitators, challenges and barriers).

Initiators and triggers

Across the case stories, multisectoral and intersectoral action was initiated primarily for three
reasons: (i) when the health sector was unable to address health and well-being challenges
on its own; (ii) to improve coherence across sectors; and (iii) to mobilize increased resources
for improving health and well-being.

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Three elements were identified as the most frequent triggers for initiating multisectoral and
intersectoral action: (i) high-level political support from ministers and ministries responsible
for health and well-being, (ii) engagement from WHO, and (iii) the introduction of data and
evidence.

Policy areas

In the case stories collected, multisectoral and intersectoral action for health and well-
being focused on an array of different policy areas. Most common, however, were the three
policy areas of broader national or regional health policies, the prevention and control of
noncommunicable diseases (NCDs) and health promotion in schools.

Implementation actions

The multisectoral and intersectoral approaches to health and well-being presented were
implemented in various ways, at different levels and in different contexts. They primarily took
the form of strategies and action plans, longer-term initiatives rather than short-term projects
and as permanent coordinating structures. Interministerial committees were identified as the
primary mechanism through which these forms of multisectoral and intersectoral action were
initiated, established and implemented.

Implementation was seen predominantly at the national level as indicated in 20 of the 36 case
stories; by contrast, only four case stories had an international dimension. A local level dimension
to the multisectoral and intersectoral action was far more common, occurring in 14 case stories;
eight of these were examples of coherence between the national, regional and local levels
but only two also included coherence at the international level. This coherence throughout the
levels, from international through national and regional to the local level, could be strengthened
through increased WHO support to local level implementation through existing networks such
as the WHO European Healthy Cities Network and the Regions for Health Network.

Facilitators

Several factors were found to enable and facilitate the implementation of multisectoral and
intersectoral action for health and well-being, including political will and good governance; a
clear mandate to reach out beyond the health sector; sufficient resources; supporting data
and evidence; sufficient capacity; strong cross-sectoral collaboration; and civil society and
media engagement, along with other contextual factors. In particular, identifying co-benefits
and ‘win–win’ situations proved essential in motivating actors beyond the health sector to
consider health and well-being goals in their activities.

The most obvious co-benefit identified was that many policy goals and objectives outside
the health sector are easier to attain with healthy people; healthy people are productive

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and better contribute to the social and economic development. Other co-benefits include
an increased exchange of information across different sectors, more effective and efficient
implementation of evidence-informed policies, and improved coordination between sectors.
In the case stories presented, the focus remains mainly on the health-related benefits, which
included an enhanced capacity to address health challenges, increased financing for health
promotion, strengthening equity goals, decreased duplication of work, new cross-sectoral
health indicators, and increased coherence.

The quality of cross-sectoral collaboration at the interpersonal level was also seen to be
a determining factor; the early engagement of collaborators, effective working methods,
trust, and open communication were considered to be critical for success. Other facilitating
factors include the engagement of civil society and international partners. A number of cases
highlighted the role of public pressure and media involvement in persuading governments to
implement comprehensive cross-sectoral initiatives to tackle various health and well-being
challenges. Additionally, some contextual factors were identified as facilitators and enablers,
such as the smaller size of the Member State, the working culture of governing jointly,
openness of the system to allow learning and the implementation new mechanisms, and an
environment that encourages risk, creativity and innovation.

Challenges and barriers

Many of the challenges and barriers to multisectoral and intersectoral action for health and
well-being are the contrast to the facilitating factors. A lack of political will or commitment
has been cited as a clear challenge. Other common challenges include a lack of resources
and coordination; inability or failure to identify co-benefits and to act in win–win situations;
poor communication and ambiguous use of language; and entrenched siloed thinking, where
resources are restricted for use only within a specific sector or programme. In a few cases, the
health sector’s own perceived superiority was mentioned as a barrier to collaboration with other
sectors. In several cases, multisectoral and intersectoral approaches struggled to overcome
conflicting interests between sectors, power imbalances and competition for resources, which
made sustainability over time unachievable. A change of government or ministers was also
found to present a challenge in terms of continuity and sustainability of policies and initiatives.

Recommendations
The case stories here suggest that the implementation of multisectoral and intersectoral
initiatives could be strengthened by providing policy-makers, civil servants and technical
experts with training on how to coordinate and structure multisectoral and intersectoral work
in practise. One common concern was that high-level policy recommendations and guidelines
were not translated into action because their implementation was not adequately supported.
Suggested themes for training included general guidance on multisectoral and intersectoral

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coordination, developing new engagement and mobilization strategies for different stakeholders
and developing improved indicators and other monitoring tools for measuring progress. In terms
of improving coherence among all levels of governance, WHO could give stronger support for
implementation across levels, from international to local, through existing networks such as the
WHO European Healthy Cities Network and the Regions for Health Network.

More specifically, a need was identified for tools and toolkits for planning, implementation and
monitoring of multisectoral and intersectoral action. Several case stories called for broader
public health education at the tertiary level, with a focus on the competencies necessary
across sectors for effective implementation multisectoral and intersectoral initiatives.

Summary of main conclusions

Overall, the analysis found that multisectoral and intersectoral action for health and well-being has
the potential to provide the transformative change called for by the 2030 Agenda and to mobilize
additional resources for health and well-being. However, approaches need to be integrated into
a new model of governance for health and well-being that is built around a stronger focus on
partnerships, through a whole-of-society approach, and increased governance coherence, both
horizontally across sectors and vertically through all levels of governance.

A new model of governance for health and well-being requires high-level political support.
With this, multisectoral and intersectoral action for health and well-being can be an integral
element of long-term political visions and strategies, ensuring sustainability for multisectoral
and intersectoral approaches over time, and the building of a strong, accountable foundation
for partnerships and collaboration in the era of the 2030 Agenda.

Moving forward, the data and analysis from this exercise can be used to inform and contribute
to a new and improved model of governance for health and well-being. Achieving the 2030
Agenda and fulfilment of the strategic objectives of Health 2020 require transformative
governance. This necessitates the involvement of diverse actors across all levels of
government, and beyond, if global, regional and national goals and targets are to be achieved
and today’s complex global challenges effectively addressed.

The mapping exercise can contribute to addressing a number of gaps in the current
understanding of multisectoral and intersectoral approaches. It highlights the need for an
enhanced focus on governance for health and well-being, and for a framework and tools to
aid Member States in implementation. The Member State case stories also contribute to an
improved understanding of the role of the WHO Regional Office for Europe in supporting
inter- and multisectoral action, both through engagement and support at the country level
and through developing and delivering the new models of governance required to support
multisectoral and intersectoral for health and well-being throughout the 53 Member States.

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Introduction
There is a long-standing consensus that the root causes of poor health and well-being cannot
be solved without addressing their underlying determinants. As these determinants span
sectors beyond the health sector, addressing them requires collaboration and partnerships with
other sectors. Multisectoral and intersectoral action is therefore critical (Box 1) for addressing
many of today’s most pressing challenges for improving health and well-being. In particular, it
is necessary for the achievement of the goals and targets of the 2030 Agenda (1) and of the
strategic objectives of Health 2020 (2), the framework guiding health policy throughout the
WHO European Region and which aims to improve health for all, reduce health inequalities
and improve leadership and participatory governance for health and well-being.

Utilizing whole system approaches such as whole-of-government, whole-of-society and

HiAP, as well as other multisectoral and intersectoral approaches can strengthen governance
for health and well-being by improving coherence and coordination across sectors and by
enhancing accountability and responsibility in sectors that impact health and well-being.

Box 1. Definition of intersectoral action for health and well-being

This report uses an umbrella term intersectoral action for health and well-being to refer to a number
of approaches that highlight the importance of working collaboratively across sectors (e.g. a whole
of government, whole of society, HiAP, healthy public policy and social determinants of health) to
improve health and well-being.
As a general definition, WHO and the Public Health Agency of Canada have described intersectoral
action for health and well-being as “actions undertaken by sectors outside the health sector,
possibly, but not necessarily, in collaboration with the health sector, on health or health equity
outcomes or on the determinants of health or health equity” (3).
The intersectoral action can be contrasted with action within a single sector, which is appropriate
when one sector has complete or near-complete control or influence over a given health problem
However, a wide range of social and environmental factors influence health and, therefore, an
intersectoral approach is preferable in many situations, “to achieve health outcomes in a way
which is more effective, efficient or sustainable than might be achieved by the health sector
working alone” (4).

Multisectoral and intersectoral action for health and well-being: a

long-standing consensus
Many of the determinants of health and well-being – commercial, cultural, economic,
environmental, political and social – are influenced by policies beyond the health sector.
Therefore, multisectoral and intersectoral action is required for effective health promotion at
the local, national, regional and global levels.

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Recognition of the importance of a multisectoral and intersectoral approach to health

policy dates back as far as the Alma-Ata Declaration of 1978, where Article 4 called for the
involvement of all related sectors in efforts to promote health (5). In the 1980s, the health
for all movement highlighted the importance of intersectoral collaboration and of prioritizing
equity in health policy (4,6); in particular, the 1986 Ottawa Charter put forward the concept of
healthy public policy and called for the involvement of other sectors in health promotion (7).

More recently, the seminal 2008 report of the WHO Commission on the Social Determinants
of Health revived calls to address the root causes of ill health through intersectoral action for
health and well-being (8). The Commission stated that reducing health inequalities would
require actions to “improve daily living conditions” and “to tackle the inequitable distribution of
power, money, and resources” (8). In 2011, the Rio Political Declaration called for increased
engagement of all sectors, stating that “We understand that health equity is a shared
responsibility and requires the engagement of all sectors of government, of all segments of
society, and of all members of the international community” (9).

In 2013, the review of social determinants and the health divide in the WHO European
Region recommended developing more “partnerships at all levels of government that
enable collaborative models of working, foster shared priorities between sectors and ensure
accountability for equity” (10). Globally, intersectoral action for health and well-being was called
for in the Sixty-seventh World Health Assembly resolution A67/R12 (11). The 65th session
of the Regional Committee for Europe discussed the working paper Promoting intersectoral
action for health and well-being and well-being in the WHO European Region: health is a
political choice (12), which concluded that “intersectoral action is difficult to achieve, yet it is
essential for the coherence, synergy and coordination of various sectors and provides a basis
for accountability in the area of health”.

Current approaches to multisectoral and intersectoral action for

health and well-being and well-being
The 2030 Agenda consists of 17 Sustainable Development Goals (SDGs) with 169 targets
that Member States aim to achieve (1,13) (Box 2). Goal 3 focuses explicitly on health, with
13 specific targets; however, almost all other goals are related to or contribute to health and
well-being (14). Work related to the SDGs is multisectoral and intersectoral in nature and,
therefore, the 2030 Agenda (1) constitutes an important policy framework that can further
action on the social determinants of health and promote greater health equity on a global
scale. Establishing a better understanding of the challenges and facilitators for multisectoral
and intersectoral collaboration can better inform policy-making and help to achieve the SDGs
and their accompanying targets.

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Box 2. The United Nations 2030 Agenda for Sustainable Development and the Sustainable
Development Goals (SDGs)
The United Nations 2030 Agenda for Sustainable Development was adopted by all 193 Member
States of the United Nations at the United Nations Sustainable Development Summit on 25
September 2015 in New York.
The 17 Sustainable Development Goals (SDGs), otherwise known as the Global Goals, are a
universal call to action to end poverty, protect the planet and ensure that all people enjoy peace
and prosperity. They build on the successes of the Millennium Development Goals, while including
new areas such as climate change, economic inequality, innovation, sustainable consumption,
peace and justice, among other priorities. The goals are interconnected and require multisectoral
and intersectoral action – the key to success for any one goal will involve tackling issues more
commonly associated with another.

Health 2020 highlights the importance of multisectoral and intersectoral action, through
whole-of-government and whole-of-society approaches, to tackling the European Region’s
most pressing health challenges (2). Conceptually, the Health 2020 policy framework is
built on improving governance for health, which is defined as “to steer communities, whole
countries or even groups of countries in the pursuit of health as integral to well-being through
both whole-of-government and whole-of-society approaches” (2). The whole-of-government
approach refers to “the diffusion of governance vertically across levels of government
and arenas of governance and horizontally throughout sectors” (2). The whole-of-society
approach extends the sphere beyond the traditional governmental decision-making by calling
for increased engagement of the private sector, civil society, communities and individuals in
health-related actions.

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HiAP is a more recent whole-system approach that aims to integrate health considerations
into policies that lie outside the health sector. The term was first used in 2006, when Finland
adopted it as a theme during its European Union (EU) presidency. HiAP has been defined as
an approach that “systematically takes into account the health and health-system implications
of decisions, seeks synergies and avoids harmful health impacts” (15). These principles
were endorsed in the 2013 Helsinki Statement on Health in All Policies at the Eighth Global
Conference on Health Promotion (16). In addition, WHO has produced comprehensive
training materials in order to facilitate the understanding and implementation of the HiAP
approach (17).

The availability of reliable and accurate health statistics is an essential requirement to the
multisectoral and intersectoral work of WHO. In addition to quantitative data, there have
been increasing calls to broaden data collection efforts through the increased utilization of
qualitative methods, such as the collections of case studies and narratives on successful policy
interventions and initiatives; this study contributes to the latter area. For example, the WHO
expert group on the cultural context of health and well-being recommended that WHO should
work to enhance its current reporting “through the use of new types of evidence, particularly
qualitative and narrative research” (18). The European Health Report 2015 called attention to
the need to collect more qualitative data on policy interventions to help in understanding the
degree to which policies implemented in one context are transferable to other cultures and
communities (19).

Overview of the report

To support multisectoral and intersectoral action for health and well-being, the Division for
Policy and Governance for Health and Well-being at the WHO Regional Office for Europe
conducted a multisectoral and intersectoral mapping exercise from 2015 to 20117. The
exercise aimed to identify examples of good practice for multisectoral and intersectoral
action for health and well-being and to share lessons learned and best practices for health
policy development and implementation. The aim was to inform and inspire ministries and
health policy-makers to strengthen cross-sectoral collaboration for health and well-being.
The first part of the exercise in 2015 involved internal consultation with 28 programme
managers, unit leaders and technical officers within the WHO Regional Office for Europe
to identify multisectoral and intersectoral actions for health and well-being. The second
part was undertaken in 2015 and 2016 and involved external consultation with 36 Member
States of the WHO European Region. From this a case story for each Member State was
identified. Analysis of the findings was undertaken in 2017 and is presented in this report. The
methodology used for the exercise is outlined followed by the key findings from the 36 case
stories and then the case stories themselves. Annex 2 is the questionnaire used to collect the
case stories.

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Methodology
Table 1 outlines the two parts of the multisectoral and intersectoral mapping exercise. Part
One consisted of an internal mapping within the WHO European Office. Part Two was external,
with case stories or narratives of good practice, detailing multisectoral and intersectoral
initiatives drafted through consultations in 36 Member States of the WHO European Region.

Table 1. Mapping exercise

Sources Method of data collection Key outputs

Part I: internal mapping Internal consultations with 28 Working paper
(2015): WHO Regional Office programme managers, unit Collection of multisectoral and
for Europe leaders and technical officers intersectoral initiatives and
mechanisms
Part II: external mapping Consultations with WHO Summary report
(2015–2016): Member States national focal points and Subregional reports
Member State representatives
A compendium of case stories

The methodological approach for Part Two - the external, Member State-focused, part of
mapping exercise was finalized at two meetings, the first on 2 December 2015 and a follow-
up meeting on 19 February 2016, held at the WHO European Office for Investment for Health
and Development in Venice, Italy. The exercise focused on the collection of case stories
(narratives of good practice) detailing successful examples of multisectoral and intersectoral
action for health and well-being at the local, regional/subnational, national and international
levels. The resulting case stories identified the structures, entry points, mechanisms and
instruments that policy-makers had used to address health and well-being challenges situated
between sectors across the WHO European Region.

Case selection and data collection

The WHO Regional Office for Europe contacted all 53 Member States through official
channels to notify them of the mapping exercise and to request that they identify an example
of successful multisectoral and intersectoral action for health and well-being that met one or
more of the following four criteria:

• addressed one or more of the strategic entry points for multisectoral and intersectoral
action;
• showed strategic or high-level political commitment and involvement;
• demonstrated a whole-of-government approach; or
• demonstrated a whole-of-society approach, including involvement from civil society.

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They also requested that Member States nominated a representative, who was familiar with
the example selected. This was usually facilitated by national focal points within ministries
of health of the respective Member States. Fig. 1 has an overview of the case selection and
data collection process.

Fig. 1. Case selection and data collection process

WHO asks Member States to identify a case story and to

nominate a Member State representative

A national focal point at the Ministry of Health identifies a

Member State representative for an interview

An external consultant schedules an interview with the Member

State representative (in-person, phone, via Skype)

An interview is conducted and the finalized case story is send

back to the Member State for validation

To manage the data collection process, the Member States were grouped into six clusters.
Three of the clusters were based on pre-existing WHO policy networks (Nordic/Baltic Policy
Dialogue, South-eastern Europe Health Network (SEEHN) and the Small Countries Initiative
(SCI)), and the remaining Member States were grouped geographically (central, eastern and
western Europe) (Table 2). Each cluster was assigned to a consultant with previous experience
with the allocated Member States. The selected examples of successful multisectoral and
intersectoral action and the contact details of the nominated Member State representatives
were then passed on to the respective consultant to facilitate data collection in the form of
case-stories.

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Table 2. Member State clusters for the external mapping

Nordic SEEHN SCI Central Eastern Western

and Baltic Europe Europe Europe
Member
States
(Nordic/
Baltic Policy
Dialogue)
Denmark Albania Andorra Austria Armenia Belgium
Estonia Bosnia and Cyprus Czech Azerbaijan France
Herzegovina Republic
Finland Bulgaria Iceland Hungary Belarus Germany
Iceland Croatia Luxembourg Poland Georgia Greece
Latvia Israel Malta Slovakia Kazakhstan Ireland
Lithuania Romania Monaco Slovenia Kyrgyzstan Italy
Norway Republic of Montenegro Switzerland Russian Netherlands
Moldova Federation
Sweden The former San Marino Tajikistan Portugal
Yugoslav
Republic of
Macedonia
Serbia
Turkey Spain
Turkmenistan United
Kingdom
Ukraine
Uzbekistan

Notes: These clusters were formulated for this exercise and do not resemble an official categorization of WHO;
Iceland is included in two Member State clusters: the Nordic and Baltic cluster and the SCI cluster but the consultant
responsible for the SCI cluster collected and reported Iceland’s case story.

Country level consultations were carried out by six external consultants to construct case
stories of successful multisectoral and intersectoral actions for health from each Member
State. The consultations consisted primarily of semistructured interviews in person or via
Skype, although a few Member States expressed a preference for submitting a written
response. To ensure that data were collected systematically, a template was created to guide
the consultation (both the semistructured interviews and written responses) (Annex 2). The
template comprised (i) background information, (ii) setting and implementation, (iii) policy
considerations, and (iv) impact and lessons learned.

From the data collected, the consultants constructed the case stories, which were then verified
by the individuals who provided the data (Table 3). The data gathered in the templates was
also entered into NVivo, a qualitative data analysis software package, for preliminary analysis.

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Table 3. List of Member State case stories by cluster

Cluster Member State Case story title

Nordic and Baltic Denmark Intersectoral action for health and well-being at the
municipal level: implementing health promotion
packages
Nordic and Baltic Estonia National Health Plan 2009–2020
Nordic and Baltic Finland Health in all policies (approach)
Nordic and Baltic Latvia Advisory Council for Maternal and Child Health:
intersectoral action with the civil society
Nordic and Baltic Lithuania State Health Affairs Commission
Nordic and Baltic Norway National system for follow-up of public health
policies in Norway: a common cross-sectoral
reporting system
Nordic and Baltic Sweden Promoting social sustainability through
intersectoral action at the local and regional level
SEEHN Albania Introducing a smoking ban in Albania
SEEHN Bosnia and Herzegovina Mental health services at the community level
SEEHN Croatia Intersectoral Committee on Environment and
Health
SEEHN Israel A Government decision to promote healthy, active
living
SEEHN Romania Integrated community-based services for health
and well-being
SEEHN Republic of Moldova Reproductive health strategy
SEEHN Serbia Implementation of the Protocol on Water and
Health in Serbia
SEEHN The former Yugoslav Republic Government Committee on Environment and
of Macedonia Health
SCI Andorra An intersectoral approach to tackle childhood
overweight and obesity (the Nereu Programme)
SCI Cyprus A National Strategy and Action Plan to Fight
Sexual Abuse, Exploitation of Children and Child
Pornography
SCI/Nordic Iceland Establishment of a Ministerial Council on Public
Health: a public health milestone for Iceland
SCI Luxembourg Get moving and eat healthier! A decade
of intersectoral action to reduce obesity in
Luxembourg
SCI Malta A whole-of-school approach to healthy lifestyles:
healthy eating and physical activity
SCI Monaco Intersectoral collaboration to test an alert system
for arrival of highly infectious diseases by sea

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Findings
This section provides an overview of the preliminary findings of the mapping exercise. Overall,
high-level political support and ensuring a long-term view to the design and implementation
of multisectoral and intersectoral action for health and well-being was viewed as critical for
success and sustainability over time. Key factors for success included engendering a sense
of ownership; fostering a strong, trusting foundation within partnerships and collaborations;
and ensuring that experts and civil servants were given autonomy when creating this
foundation. Furthermore, the majority of the case stories indicated that positive experiences
with multisectoral and intersectoral action for health and well-being would be transferable to
other Member State environments.

The findings are discussed in terms of (i) factors that contribute to the initiation of multisectoral
and intersectoral action for health and well-being, including why multisectoral and intersectoral
approaches were initially pursued; (ii) the scope and focus of the policies, with particular
attention paid to the extent to which cross-cutting areas such as gender, equity and human
rights were prioritized; (iii) implementation, including the level of implementation, the form that
multisectoral and intersectoral actions took, facilitating mechanisms and the challenges and
barriers identified; and (iv)the overall findings of the impact of multisectoral and intersectoral
action for health and well-being and lessons identified in the case stories.

Initiating multisectoral and intersectoral action for health and well-

being

Why multisectoral and intersectoral action?

Across case stories, multisectoral and intersectoral action for health and well-being was
undertaken primarily for three reasons: (i) when the health sector was unable to address health
and well-being challenges on its own; (ii) to improve coherence in addressing health and well-
being challenges across sectors; and (iii) to increase and mobilize resources dedicated to
improving health and well-being.

First, the majority of Member State representatives indicated that a multisectoral and
intersectoral approach was taken in response to health and well-being challenges that the
health sector was unable to address alone – a finding that aligns with the long history of
WHO documents calling for multisectoral and intersectoral action for health and well-being.
Often, this inability was because the health sector had neither a sufficient mandate nor
the competence to address wider determinants of health and well-being; in these cases,
collaboration with other sectors was viewed as essential.

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While a number of case stories indicated that other sectors (e.g. education) also identified
addressing health and well-being challenges as falling within their responsibilities, multisectoral
and intersectoral action was viewed mostly as a mechanism through which to raise awareness
of, and to achieve broader accountability and responsibility for, the achievement of goals
related to health and well-being.

Second, a multisectoral and intersectoral approach was thought to strengthen coherence

across sectors; within the health sector, more coherent policies were perceived to lead to
better health and well-being for all.

Third, increasing the financial resources dedicated to improving health and well-being was a
motivating factor. Health budgets tended to be limited by financial constraints and, consequently,
the involvement of others sectors was seen in part as a means of mobilizing increased
resources. In several examples it was also argued that multisectoral and intersectoral action
for health and well-being improved the collective effectiveness and efficiency of financial
resources used across sectors.

Triggers

The ministry responsible for health and well-being, WHO and the availability of data and
evidence were cited as triggers of multisectoral and intersectoral action for health and well-
being. In 12 of the 36 case stories either the minister of health or the ministry responsible for
health and well-being initiated the multisectoral and intersectoral action. Noticeably, despite
political support from the highest level being identified as a key facilitator, action taken by
the prime minister or other ministries was rarely mentioned as a trigger of multisectoral and
intersectoral action for health and well-being.

WHO was the second most frequently mentioned trigger of multisectoral and intersectoral
action for health and well-being? WHO was seen to exercise levels of influence that increased
gradually over decades, primarily through influential policy documents and guidance related
to national health policy development?

WHO documents mentioned in the interviews included Health 2020, the World Health Reports,
the final report of the Commission on Social Determinants of Health and the WHO’s NCD
strategies. The importance of data and evidence in triggering multisectoral and intersectoral
action for health and well-being was also highlighted in several case stories, emphasizing
that only knowledge of the existence and scope of a problem can lead to appropriate and
needs-based action and response.

Other triggers included the introduction of national strategies or programmes, a change in

government with new priorities, political will among politicians and pressure from the general
public, media or nongovernmental organizations (NGOs). In some cases, specific occasions
or events were also identified as triggers.

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Scope and focus of multisectoral and intersectoral policies for

health and well-being

Policy areas

The case stories were wide ranging and aimed to address a number of health-related
challenges. The coding of the cases revealed that the case stories occurred within one of
eight policy areas: (i) broad national or regional health policies, (ii) prevention and control
of NCDs, (iii) school health promotion, (iv) health system monitoring and development, (v)
environment and health, (vi) sexual and reproductive health, (vii) communicable diseases,
and (viii) antimicrobial resistance (AMR) (Fig. 2).

Fig. 2. Policy area of the 36 case stories

Broad national or regional health policies 12

Prevention and control of NCDs 7

School health promotion 4

Health system monitoring and development 3

Environment and health 3

Sexual and reproductive health 3

Communicable diseases 2

Antimicrobial resistance (AMR) 2

0 2 4 6 8 10 12 14

Approximately two thirds of the case stories fell within the first three policy areas alone, and
the following section discusses these three policy areas.

National or regional health policies

Broad national or regional health policies, including national health strategies and programmes
aimed at addressing multiple health and well-being issues and their determinants, were the
policy area most frequently highlighted in the case stories. The case stories of 12 Member
States (Czech Republic, Denmark, Estonia, Finland, Iceland, Ireland, Israel, Lithuania,
Romania, Slovenia, Sweden and Switzerland) highlighted multisectoral and intersectoral
action in this area.

Planning and implementation processes engaged multiple ministries and other stakeholders.
For example, the Healthy Ireland framework exemplifies a comprehensive and multisectoral
and intersectoral approach to health policy-making (Box 3). Furthermore, the National Health

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Plan 2009–2020 of Estonia illustrates how these broad policy frameworks can promote long-
term strategies focused on improving health and well-being over the life course (Box 4).

Box 3. Case example: Healthy Ireland 2013–2025, a framework for improved health and
well-being
Healthy Ireland (2013–2025) is a government-led, multifaceted framework to improve the health
and well-being of the population. The broad and complex nature of the framework and the massive
change agenda associated with its implementation requires that a critical focus remains on the
wider enablers of implementation, such as stakeholder consultation, building a supportive culture,
communication and leadership.
Healthy Ireland seeks to more effectively address the key lifestyle behaviour issues that result in
ill health and chronic disease, as well as the social and environmental determinants of health and
well-being, through a whole-of-government and whole-of-society approach.
The key goals of the framework include:
• increasing the proportion of people who are healthy at all stages of life;
• reducing health inequalities;
• protecting the public from threats to health and well-being; and
• creating an environment where every individual and sector of society can play their part in
achieving a healthy Ireland.

Box 4. Case example: the National Health Plan 2009–2020 of Estonia

The National Health Plan 2009–2020 of Estonia is an intersectoral, long-term strategy that aims
to improve health-adjusted life expectancy of Estonians. The plan is established by a government
regulation, and its actions are mandated by different legislative decrees.
The National Health Plan highlights that the right to health is one of the basic human rights, and
everyone must have the possibility of living in a healthy environment and an opportunity to make
healthy choices. Common values such as joint responsibility for health, equal opportunities and
justice, social inclusion and increasing power of civil society are priorities.
The Estonian National Health Plan for 2009–2020 has five thematic fields:
• increasing social cohesion and equal opportunities;
• ensuring healthy and safe development for children;
• shaping an environment supporting health;
• facilitating healthy lifestyles; and
• ensuring the sustainability of the health care system.
The Plan is implemented at national, regional and local levels, and its progress is monitored by an
intersectoral structure, the Steering Committee, which includes representatives from all relevant
ministries and departments, semigovernmental agencies and civil society. The Ministry of Social
Affairs leads the Steering Committee and acts as its Secretariat.
Clear targets and indicators are set to monitor the implementation on a yearly basis and the
monitoring mechanism is reviewed every four years. The yearly progress reports are opened for
public feedback in an online portal (eelnoud.valitsus.ee).

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Prevention and control of NCDs

The second most common policy area for multisectoral and intersectoral action was the
prevention and control of NCDs. The seven case stories in this category had a more specific
focus on the prevention of chronic diseases and its risk factors. Two of the case stories were
specifically focused on smoking and tobacco control (Albania and Georgia).

Other areas included reduction of salt intake (Montenegro), obesity (Luxembourg), mental
health services (Bosnia and Herzegovina), healthy eating and physical activity (Andorra), and
a nationwide NCD prevention strategy (Azerbaijan). Montenegro’s intersectoral programme
to reduce dietary salt intake illustrates the benefits of intersectoral action, particularly when
taken with clear targets and implementation measures (Box 5).

Box 5. Case example: intersectoral action to reduce salt intake in Montenegro

The Programme for Reducing Dietary Salt Intake in Montenegro (2014–2025), aims to reduce the
daily salt intake in the population of Montenegro to below 5 grams per capita; in line with applicable
WHO recommendations. This long-term goal will be achieved by increasing awareness and
knowledge of the population, reducing salt content in processed foods and through a harmonized
national response.
The Initiative for reducing salt in bread and baking products was launched by health sector and
included the baking industry. Following the Initiative, a National Program for reducing dietary salt
intake in Montenegro (2014–2025) was developed by a multidisciplinary team from the health
sector setting objectives and measures to be implemented intersectorally. The Programme
recommended measures that would contribute to reducing salt intake in the population by 16%
relative to the baseline levels measured, during the 2014–2020 period and by 30% by the year
2025.
Specific objectives of the Programme:
• provide essential data necessary for a successful implementation of the Programme, which will
be continuously updated and improved;
• upgrade awareness and knowledge within the population and professional public in Montenegro
as to the importance of reducing excessive dietary salt intake;
• reduce salt content in processed food, in cooperation with the food and catering industry;
• harmonize the national response to the problem of excessive dietary salt intake with successful
international solutions and experiences; and
• establish a monitoring and evaluation system for the Programme interventions.

Health promotion in schools

Health promotion in schools was the main focal area in four of the case stories (France,
Hungary, Malta and San Marino). In France, the Ministry of Health and the Ministry of Education
collaborate to educate children about health and also in monitoring their well-being. Hungary
has developed comprehensive health promotion activities in schools that cover a wide range

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of areas such as diet, physical activity, mental health, dependencies, violence prevention and
personal hygiene. San Marino has highlighted the importance of nutrition and sustainable
agriculture in the school setting, which has involved activities to ensure that children have
access to sustainably grown and nutritious foods. Finally, Malta has initiated a whole-of-
school approach to promote healthy lifestyles, with a focus on healthy diet and environments,
such as playgrounds that promote physical activity (Box 6).

Box 6. Case example: a whole-of-school approach to healthy lifestyles: healthy eating and
physical activity in Malta
The major health challenge affecting schoolchildren in Malta is that of overweight and obesity. The
rapid increase of obesity motivated the health and education sectors to join efforts in to implement
a national school-wide policy and strategy to increase physical activity and improve nutrition in
schools for all children.
The highest levels of government were involved in policy and strategy development from the
outset. Both the education and health sectors shared the lead in taking action forward. Many
levels of society have been involved in this initiative. Parent associations were consulted during
the development of the policy and in policy development through active consultation. The media
also played an active role in promotion and information dissemination.
The private sector, namely school-based snack shops called tuck shops, were key players. As
suppliers of snacks at schools, they were obliged to change their purchasing choices. The quality
of foods sold within schools at tuck shops was examined, classifying products according to the
WHO nutrient model. Tuck shop owners were given a list of permitted and non-permitted foods
that could be sold.
The strategic goals of the initiative were to:
• achieve better physical activity and nutrition for all schoolchildren in Malta; and
• create a level playing field in all schools by offering equal opportunities for all children to engage
in physical activity and benefit from improved nutrition in school settings.

Gender, equity, and human rights

The mapping exercise included an explicit focus on the extent to which gender, equity and
rights were mainstreamed throughout the case stories provided, in line with WHO global policy
(Box 7). While this focus was maintained throughout, specific questions were highlighted in
the questionnaire, indicating a further focus on these issues at specific stages of the data
collection.

Gender, equity, and rights were identified as being a particular focus in only a very small
number of case stories and were often identified together as a group. While this suggests that
they were mainstreamed in line with WHO policy when they were considered in the action
undertaken, it also indicates that they were not considered often enough. This study called
for examples of best practice and the lack of a focus on these issues necessitates attention
and should be addressed.

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Box 7. Gender, equity, and human rights in the work of WHO

At the global level, WHO released A Roadmap for Action (2014–2019) for integration equity,
gender, human rights and social determinants into the work of WHO (20). The roadmap consists
of three pillars: (i) institutional mainstreaming of equity, gender and human rights in WHO
programmes, (ii) monitoring of health inequalities and supporting data disaggregation, and (iii)
providing support to WHO Member States. The progressive realization of the right to health should
entail a sustained effort to improve health for the population as a whole, but also efforts to reduce
unfair and avoidable inequalities between socioeconomic groups within the population. The WHO
Handbook for Guideline Development (21) states: “The planned achievements should focus not
only on the average level of health, but also on how health is distributed within populations and
across groups. The idea is to ensure that those of lower social position and with greater needs can
benefit more than more advantaged persons. Through this progressive realization of the right to
health, a levelling-up of health status is achieved across the population.”

Additional work and commitment is needed to enhance data collection and strengthen the
evidence base, not only for policy planning but also for monitoring and evaluation. These
data should also be disaggregated according to a number of socioeconomic variables,
including gender. The case story from Norway is a particularly positive example of enhanced
data collection on equity, where intersectoral action led to the development of health equity
indicators that have continued to propel intersectoral action for health and well-being
throughout the Member State (Box 8).

From a governance perspective, to ensure gender, equity, and rights manifest in policy outputs
and implementation outcomes requires using gender, equity, and rights-based approaches
from the outset of policy design, and throughout implementation, monitoring and evaluation.

Box 8. Case example: Norwegian common health equity indicators

Norway has a long history related to intersectoral action for health and well-being, which has been
implemented at different levels of governance and has been supported by a wide array of tools
and mechanisms. Gender, equity and human rights are cross-cutting themes in this work. For
indicators, data are disaggregated according to socioeconomic variables and gender. Data are
also collected for vulnerable groups.
White Paper 20 (2006–2007), National strategy to reduce social inequalities in health, highlighted
public health policy as a cross-sectoral issue and first launched the cross-sectoral reporting
system. The document recommended that cross-sectoral tools should be adopted to support
efforts to reduce health inequalities, including establishing a review and reporting system to
monitor developments in the work on reducing social inequalities in health. The reporting system
is a feedback mechanism for intersectoral indicators on determinants/progress across sectors that
constitutes a basis for further policy development.
White Paper 34 (2012–2013), Public health report – good health, a common responsibility,
reinforced the need for collective action on health and established a national system for the follow-
up of public health policies. In order to support this work, different sectors have collaborated
to create indicators across sectors to feed back to policy development. The collaboration has
strengthened the focus on socioeconomic indicators and thereby stimulated the equity agenda
across the Government.

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Implementation of multisectoral and intersectoral policies for health

and well-being

Forms of multisectoral and intersectoral action

The thematic coding of the case stories reveals that multisectoral and intersectoral action
for health and well-being took one of six forms: (i) strategies and action plans, (ii) long-
term multisectoral and intersectoral initiatives, (iii) permanent structures, (iv) projects, (v)
legislative or parliamentary decisions, and (vi) tools1 (Fig. 3).

Fig. 3. Form of multisectoral and intersectoral action in the 36 case stories

Strategies and actions plans 15

Long-term multisectoral and

7
intersectoral initiatives

Permanent structures 6

Projects 3

Legislative or parliamentary decisions 3

Tools 2

0 2 4 6 8 10 12 14 16

In the majority of case stories, multisectoral and intersectoral action took one of the first
three forms: strategies and action plans in 15 (Azerbaijan, Cyprus, Czech Republic, Estonia,
Georgia, Germany, Ireland, Luxembourg, Malta, Monaco, Republic of Moldova, San Marino,
Slovenia, Spain and Switzerland), long-term multisectoral and intersectoral initiatives in
seven(Andorra, Austria, Croatia, Finland, France, Montenegro and Romania), and permanent
structures in six (Iceland, Latvia, Lithuania, Serbia, Sweden and the former Yugoslav Republic
of Macedonia).

In 29 of the 36 cases stories, interministerial committees were the mechanism through

which multisectoral and intersectoral action was realized. These committees involved a
range of members and actors, including ministers, deputy ministers or other ministerial
representatives, such as senior officials or technical experts. Several cases described the
existence of a cabinet committee that was chaired by the prime minister. However the
mandate and influence of these committees varied, and there are many open questions on

1 These categories are not mutually exclusive; strategies and action plans may use legislative devices or specific
tools in their implementation. However, the categories used highlight the primary form or mechanism of intersectoral
action.

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how these committees functioned, particularly regarding the closeness of the cooperation
and the working methods.

Governance coherence

Coherence between different levels of governance is just as important as coherence

across different sectors of government. In addition to promoting horizontal collaborations
and partnerships across sectors, multisectoral and intersectoral action for health and well-
being also takes place vertically between the international, national, subnational/regional
and local levels. Table 4 groups the case stories into six types based on their vertical level
of implementation. The majority were implemented solely at the national level (20 Member
States). The second most common type involved a combination of national, regional and
local level implementation (eight Member States) with four Member States using national-
local implementation.

Table 4. Level of implemenation of multisectoral and intersectoral action for health and well-being

Implementation level Member States

National Albania, Andorra, Armenia, Austria, Azerbaijan, Croatia,
Cyprus, Czech Republic, Georgia, Hungary, Iceland, Latvia,
Luxembourg, Malta, Montenegro, Republic of Moldova, San
Marino, Serbia, Slovenia, the former Yugoslav Republic of
Macedonia
National–regional–local Denmark, Estonia, France, Ireland, Lithuania, Norway,
Spain, Sweden
National–local Bosnia and Herzegovina, Finland, Israel, Romania
International–national–regional–local Belgium, Germany
International–national Monaco (with France)
International Switzerland

Ensuring that coherence extends down to the local level is vitally important, as it is at the local
level that implementation occurs. For a policy or action to be most effective, coherence must be
present from the international level through the intermediate levels and extending to the local
level. This is necessary to ensure the implementation of WHO global and regional policies. A
local dimension to the multisectoral and intersectoral action was identified far more frequently
than an international dimension, with 14 case stories in total including it. While eight of these
were examples of coherence between the national, regional and local levels, only two of also
included coherence with the international level. This coherence from the international level
could be strengthened through increased WHO support to local level implementation through
existing networks such as the WHO European Healthy Cities Network and the Regions for
Health Network.

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Enabling and facilitating factors

Numerous factors were found to enable and facilitate multisectoral and intersectoral action
for health and well-being (Box 9). Many of these factors are contextual but case stories also
identified more general facilitating factors, including political will and good governance; a clear
mandate; sufficient resources; data and evidence; multisectoral and intersectoral capacity;
quality multisectoral and intersectoral collaboration; and civil society and media engagement,
in addition to other contextual factors.

Box 9. Enabling and facilitating factors for implementing multisectoral and intersectoral
action for health and well-being

• High-level political support and commitment for multisectoral and intersectoral action
• Focus on the long-term outcomes and policy changes
• Existence of a clear mandate
• High-quality evidence and information for policy planning and monitoring
• Adequate financial and human resources for implementation
• Competence of the health sector to reach out to other sectors
• Cross-sectoral relationships based on trust and shared understanding of the problem
• Clear objectives and identified co-benefits among partners
• Engagement of the civil society
• Public pressure
• Media support and involvement.

Political will and good governance

Political will, particularly in the form of high-level political support, was cited as the most
important factor for the successful implementation of multisectoral and intersectoral initiatives.
High-level ministerial support that transcended the health sector was reported in over 20
case stories; the involvement of the minister responsible for health and well-being was seen
as essential in successful implementation. In one of these case stories, multisectoral and
intersectoral action was supported by the president of the Member State and in five by the
prime minister directly.

Several case stories highlighted that high-level participation influences and mobilizes other
levels of governance, emphasizing that it is difficult to carry out multisectoral and intersectoral
initiatives without support and leadership from the uppermost levels of government. Top-level
involvement and commitment was seen as a requirement for legitimizing multisectoral and
intersectoral action at other levels of government, such as the regional and local levels.

The involvement of parliaments and political parties across the spectrum was seen to be
essential in addressing certain health challenges. The participation of high-level politicians

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was seen as one key indication of political will and determination. Furthermore, the importance
of civil servants and regional authorities was also highlighted as important in order to attain
sufficient capacity and commitment for implementation. According to those interviewed,
political will was expressed in the formulation of high-level committees or councils, as well
as in the adoption of parliamentary resolutions or national programmes and action plans that
address specific health and well-being issues.

Finally, a long-term focus was also identified as a critical success factor. Successful
multisectoral and intersectoral initiatives could not focus only on short-term gains because it
was clear that sustainable outcomes would usually take a prolonged period of time to achieve.
In this case, political will was demonstrated by taking initiative and establishing mechanisms
for planning and implementation.

Mandate

A clear mandate for action beyond the health sector was seen as essential for facilitating the
successful and sustainable implementation of multisectoral and intersectoral action for health
and well-being. A mandate refers to the authority to take action on a certain area. In terms
of multisectoral and intersectoral action for health and well-being, the issue of mandate is
important because, by definition, multisectoral and intersectoral action require that the health
sector works in a manner that can sometimes be construed as extending beyond its mandated
area. The majority of the 36 cases stories were supported by an identifiable mandate; there
were only four cases in which a clear supporting mandate was not articulated. A clear mandate
was also thought to be an indicator of high-level political support and commitment.

Most commonly, the mandate was based on government decisions, laws and resolutions.
The integrity of the mandate was ensured through the clear delineation of responsibilities,
sufficient resource allocation, identified outcome targets and the presence of monitoring and
evaluation mechanisms. It was considered essential that the supportive legislation was in
place in order to carry out multisectoral and intersectoral work effectively, and in many cases,
the legislative base was supported by detailed implementation strategies, programmes and
action plans.

Resources

Sufficient financial and human resources for planning, implementation and monitoring were
also considered as essential facilitating factors in successful multisectoral and intersectoral
initiatives. Supportive institutions were seen to facilitate multisectoral and intersectoral work
through good coordination and proper organizational structures. In some cases, joint funding
initiatives were used to stimulate multisectoral and intersectoral projects and partnerships.

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Data and evidence

Data and evidence were seen to be driving forces, and in some cases prerequisites, for
multisectoral and intersectoral action for health and well-being. Data and evidence inform
an understanding of both the importance of many health challenges, and the benefits that
a multisectoral and intersectoral approach can provide in addressing these. Reliable data
help to set indicators and targets that can be monitored, and data collection should be
disaggregated according to a number of socioeconomic variables whenever possible (e.g. by
income, gender, level of education, occupation).

Additionally, data can be used to convince decision-makers and other sectoral ministries to
take multisectoral and intersectoral action. Evidence and recommendations from WHO and
other international organizations were also seen as facilitating multisectoral and intersectoral
collaboration for health and well-being. However, several respondents cautioned that
imposing health-related goals and targets on other sectors without understanding the unique
challenges and policy processes of the other sector would most likely be counterproductive.

Enhanced data collection and the formation of a strong evidence base are necessary to
supplement and complement good governance, clear communication and the building of
strong partnerships across sectors, in order for multisectoral and intersectoral action for
health and well-being to be successful.

Multisectoral and intersectoral capacity

Increasing and building the capacity of the health sector to engage other sectors more
effectively was seen as a key factor in facilitating multisectoral and intersectoral action.
Several case stories indicated that the use of health language could be counterproductive
when seeking to establish working relationships with other sectoral ministries.

Widening the discussion to include other goals, such development and social sustainability,
was seen as a successful means of fostering multisectoral and intersectoral engagement.
It was also noted that, in many cases, representatives from the health sector did not fully
understand the goals and dynamics of other sectors. Attempting to impose health-related
goals on other sectors without understanding the unique challenges and policy processes of
other sectors was often deemed to be counterproductive.

Multisectoral and intersectoral collaboration

The quality of multisectoral and intersectoral collaboration was one of the main factors that
determined the outcomes. The success factor most often mentioned was having a focus on
creating good relationships based on trust and open communication. It was indicated that
building these relationships often took a substantive period of time and required determined

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action to overcome potential divisions. The notion that multisectoral and intersectoral
collaboration helps to reach the goals of all sectors involved was a key facilitating factor, as
was a consensus regarding the action deemed suitable, feasible and acceptable. Additional
factors related to the building of strong relationships included effective working methods,
quality and reputation of partners and ensuring an appropriate environment to facilitate the
receptiveness of different partners to collaboration more broadly.

Clearly identified mutual goals and co-benefits were shown to increase the commitment of
all parties involved. Early engagement with other sectors, as well as the ability to identify
common ground, was described as crucial for success. The attainment of co-benefits refers
to a situation where different sectors identify mutually beneficial results for themselves. For
the health sector, it is important to identify these win–win situations in order to increase the
commitment to health-promoting goals beyond sectoral boundaries, and to motivate actors
outside the health sector to consider health and well-being goals in their activities.

The most obvious co-benefit that the health sector can bring to other sectors is that goals
across most sectors are easier to attain with healthy people, in particular economic goals.
Healthy people are productive people who contribute to social and economic development.
Increased exchange of data and information across different sectors was also identified as a
co-benefit that can lead to better evidence-informed policies and more effective implementation
in all sectors involved. This is crucial in ensuring that nobody is left behind, and nobody falls
through gaps in service delivery (e.g. between social, education and health sectors), which is
a central element of the 2030 Agenda. More efficient and effective coordination was identified
as a mutual benefit that extends beyond the health sector.

From the health perspective, the benefits of collaboration include an increased capacity
to address health challenges, which sometimes includes increased financing for health-
promoting activities. Moreover, strengthening equity goals was seen as a mutually benefiting
development that has implications beyond the health sector. Improved monitoring and
decreased duplication of work was seen as equally beneficial. In some cases, multisectoral
and intersectoral collaboration had led to the development of new indicators, as well as more
comprehensive multisectoral and intersectoral policies that addressed health and well-being
problems through a win–win approach. These improved methods of collaboration were seen
to signify increased coherence and facilitate a more systematic approach to addressing public
policy challenges.

Successful multisectoral and intersectoral action for health and well-being was seen to induce
health-promoting changes in other sectors, such as giving a higher priority to health concerns
or the alteration of governance mechanisms to improve health and well-being. Changes in
sectors besides health were reported in 27 of the 36 case stories. The nine cases that did
not induce changes in other sectors were limited in their scope, and direct changes across
sectors were not necessarily expected.

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The emphasis on the notion that good health is good for everyone led to the integration
of health goals into the activities of non-health sectors. Some of the concrete examples
included minimizing the use of antibiotics in livestock (agriculture), reducing the used of salt
in food production (agriculture), providing more physical activity and healthier diets in schools
(education) and increasing taxes on alcohol and tobacco (finance). In the future, it is important
to reach collaborators who represent sectors other than health. This could involve collecting
their views on the co-benefits that can result from collaboration with health-oriented actors
and health ministries.

Civil society and the media

The engagement of civil society from the planning through to the implementation and evaluation
stages was seen to increase the legitimacy of action and to provide wider perspectives and
concerns to governments. Creating a platform for civil society participation was in itself already
a way to promote multisectoral and intersectoral collaboration. The bottom-up approach was
often seen to be helpful in raising perspectives that might be lost in more high-level, top-down
planning.

Cooperation with international partners such as WHO and the EU was seen also as a factor
that facilitated collaboration across sectors. For example, the WHO European Healthy Cities
Network and the Network of Health Promoting Schools were mentioned as existing networks
that have facilitated multisectoral and intersectoral action for health and well-being. Only a
few case stories in this mapping exercise indicated the involvement of the private sector. For
example, a mobile phone company and a privately owned media corporation were actors with
a role in two case stories.

Public pressure and media involvement were also considered as great motivators that
could facilitate multisectoral and intersectoral action. A group of active citizens can hold
governments accountable, particularly at the local level, and can persuade governments to
create comprehensive solutions to health challenges. Similarly, the media can raise awareness
and effectively disseminate information about problems that require a multisectoral and
intersectoral response.

Other contextual factors

Finally, some Member State representatives highlighted the role of various contextual factors
that have facilitated multisectoral and intersectoral collaboration. These included the small
size of the Member State, the culture of governing jointly, an openness to learn and implement
new mechanisms and having an environment that encourages creativity and innovation.

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Challenges and barriers

Typical challenges and barriers to multisectoral and intersectoral action for health and well-
being were negative aspects of enabling and facilitating factors; for example political will was
seen as a clear facilitator and lack of political will was identified as a clear challenge. In some
cases, multisectoral and intersectoral action was supported only through rhetoric, with a lack
of concrete investments into implementation.

Some Member State representatives identified a lack of political leadership that values health
and well-being. Lack of resources is often indicative of the absence of budget allocation and
adequate human resources. Another typical challenge was the difficulty in convincing other
sectors about the positive effects and financial benefits of cross-sectoral collaboration. In
these situations, co-benefits and win–win situations tended not to have been clearly identified
or articulated.

Communication was often acknowledged as a challenging area because of issues in finding

a common language and working methods for cross-sectoral work. It was indicated that
political will has to be accompanied by governance mechanisms that define both working
methods and roles and responsibilities. As one Member State representative stated, “it is
a great challenge to make other sectors actors, not spectators”. Several informants stated
that they do not necessarily have concrete tools and ways to approach other sectors. The
belief that the health sector can solve the problems of other sectors was seen to be a sign of
superiority and arrogance and, therefore, counterproductive.

Siloed thinking and resistance to adopting multisectoral or intersectoral perspectives were

also mentioned as challenges that apply to the health sector itself, as well as to other
sectors. Conflicting interests, power imbalances and competition for the same resources
were also mentioned as common barriers to multisectoral and intersectoral action. Political
changes in a government or ministries were considered a challenge in terms of continuity
and sustainability of actions. In addition, showing the cost–effectiveness of multisectoral and
intersectoral collaboration was considered challenging because there is often a lack of clear
and contextual evidence to support positive changes.

Overarching findings, insights and lessons learned

The Member State representatives shared several important findings, insights and lessons
learned in relation to the initiation and implementation of multisectoral and intersectoral
actions that are applicable to different cultural and political contexts. Many representatives
expressed a sense that multisectoral and intersectoral action is key to achieving sustainable
and substantial improvements to a number of health and well-being problems and challenges.
One of the recurring statements was that high-level political participation and support at the
national level are essential factors that help to achieve desired results and outcomes.

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Strengthening implementation by building multisectoral and intersectoral

capacity

One of the interview themes related to various ways to support and strengthen the
implementation of multisectoral and intersectoral initiatives. Member State representatives
suggested a number of capacity-building activities, such as training for policy-makers, civil
servants and technical staff on how to coordinate and structure multisectoral and intersectoral
work in practice. A main concern was that guidelines and high-level recommendations are
not translated into practice if their concrete implementation is inadequately supported. Some
suggested themes were related to questions such as:

• how coordination can be improved and good working relationships created with stakeholders
outside the health sector;
• how health advocacy and leadership can be improved for multisectoral and intersectoral
collaboration; and
• how monitoring can be improved and indicators created and used to measure progress.

Respondents commented that easy-to-use tools are needed for the planning, implementing
and monitoring of multisectoral and intersectoral action for health and well-being. Additionally,
there is a need for targeted and tailored engagement and mobilization strategies for different
groups of stakeholders, such as vulnerable or at-risk groups, civil society and NGOs.

Case studies from other Member States were seen to be beneficial because they can work
as inspiration for action in other contexts. Emphasis was placed upon developing an ability to
understand the different positions and motivations of stakeholders beyond the health sector
in order to facilitate the consensus-building processes necessary for effective implementation
of multisectoral and intersectoral action. Methods to share common challenges, facilitating
factors and strategies for approaching and engaging other sectors, as well as ways to show the
economic benefits of multisectoral and intersectoral collaboration, were requested. A common
form of presenting this information was through multisectoral or intersectoral policy briefs.

Several Member State representatives also suggested that there should be broader public
health education on multisectoral and intersectoral action for health and well-being, with
a focus on the competencies for implementing cross-sectoral initiatives. Addressing this
need would require curricula development in universities and other educational institutions.
Future generations of policy-makers should be equipped with an understanding of health
determinants and of the capacities needed to approach health issues both horizontally across
sectors and vertically at the various implementation levels.

Mobilization of resources

Member State representatives also noted that effective collaboration requires adequate time
as well as financial and human resources. Often, resources can be very limited and this poses

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challenges to the sustainability of multisectoral and intersectoral collaboration. Consequently,

setting up permanent multisectoral and intersectoral mechanisms with adequate budget
allocations was seen as important. Moreover, the existence of reliable information was
considered to be prerequisite for evidence-informed decision-making because otherwise
policy-makers could rely too heavily on information provided by various interest groups; for
example, information might be consensual but inaccurate and so would not serve citizens’
well-being. Additionally, it was hoped that there would be more support to set up permanent
evaluation mechanisms and to develop new tools for citizen participation in health-related
matters.

Impact and lessons learned

A number of lessons can be learned from the case stories about initiating and implementing
multisectoral and intersectoral action for health and well-being. High-level political support
is often one of the core requirements in order to achieve sustainable outcomes. Similarly,
multisectoral and intersectoral action for health and well-being is best supported by a clear
mandate, which includes strong mandates through provision within constitutions, laws and
decrees or soft mandates such as institutional guidelines, strategies and action plans at the
national or local level to steer affirmative action to implement multisectoral and intersectoral
mechanisms.

To be sustainable, multisectoral and intersectoral mechanisms must last beyond electoral

mandates, as political changes can quickly abolish initiatives and mechanisms that were
established by a previous government. For this reason, permanent multisectoral and
intersectoral structures for health and well-being are often looked upon favourably for their
improved chance of sustainability and longevity.

Another lesson learned included having a long-term vision and commitment that is also
operationalized in long- and short-term goals, measurable indicators and with a monitoring
and accountability framework. Unnecessary bureaucratic procedures can act as a barrier
and, therefore, engaged civil servants should be allowed reasonable levels of autonomy and
independence to implement multisectoral and intersectoral initiatives. One Member State
representative said that the importance of dedicated individual civil servants and decision-
makers should not be underestimated, because they have the potential to attain significant
success even in resource-scarce situations. Similarly, creating ownership across the sectors
was considered very important. Greater ownership can be achieved by involving key actors
from the start, communicating clearly by using accessible language, providing reliable
information and ensuring the continuity of collaborations.

It was also considered important to find the right partners and experts to exert influence on
the policy objective, and it was equally critical to identify potential or existing opposition,

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barriers and challenges. Opposition was identified as stemming from private actors with
vested interests and from strong interest groups. It was suggested that a useful strategy was
to maintain the focus of the discussion firmly on public health arguments when engaging
opposition.

With regard to transferability of lessons learned, all representatives felt that their Member
State’s multisectoral or intersectoral initiative could be implemented in another Member State.
This implies great potential in promoting a learning-through-others approach and sharing
best practice in the WHO European Region. While political, social and cultural contexts are
geographically very diverse across the WHO European Region, and policy initiatives need
to be modified and adapted accordingly, sharing of the practice of effective multisectoral and
intersectoral initiatives can inform and inspire governments for their own actions.

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Case story summaries

1. Albania: Introducing a smoking ban

Smoking is the single most preventable cause of premature mortality, increasing the risk of
lung cancer, emphysema, heart disease, stroke and other diseases. Evidence from surveys
in recent years has shown that over 50% of the Albanian adult population is smoking, putting
the country at a very unfavourable situation regarding the future costs of illness and related
complications. Motivated by such data and encouraged by positive examples of smoking bans
in other European countries, the Albanian Government initiated introduction of a smoking
ban in Albania and Albania became a party to the WHO Framework Convention on Tobacco
Control on 25 July 2006.

The intersectoral efforts were grounded in the Health 2020 framework, which offers ample
evidence on the cost–effectiveness of tobacco use prevention as a public health intervention
that requires intersectoral action.

Tobacco control policy is an excellent investment in the health of a country’s population.

According to WHO, for less than 30 lek (approx. €0.25) per person per year, Albania will be
able to pay for the four “best buys” in tobacco control policy: raising tobacco excise taxes,
enforcing a comprehensive national smoke-free law, enforcing a ban on tobacco advertising
and promotion, and mandating large graphic warning labels to appear on tobacco product
packaging. This small investment will reap enormous dividends in health and prosperity.

2. Andorra: Tackling childhood obesity and sedentary lifestyle

using a multisectoral approach: the Nereu programme

The Nereu Programme aims to promote change and maintain healthy habits in overweight and
obese primary schoolchildren by offering regular opportunities for physical activity, promotion
of healthy eating and working with families. Nereu seeks to reduce the prevalence of obesity
in the country in line with the Andorran Health 2020 goals. The Nereu programme aims to
reach 60% of overweight or obese children in the country. In Andorra, overweight prevalence
is 8% and child obesity is 5.5% in children aged 11 to 12 years.

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In Andorra, the health, education and sports sectors have a history of working together in
an Education for Health programme and implementing actions pertaining to the National
Strategy for Nutrition, Sport and Health. The Nereu programme uses an intersectoral
approach involving the health, sport and education sectors and provides equal opportunities
for participation, regardless of gender, income, education or fitness levels. Participation fees
are waived for financial reasons.

In 2015, a pilot was carried out in seven schools in Andorra and included overweight and/or
obese children with low levels of physical activity. Children attended three sessions per week
of extracurricular physical activity lessons, practised new sports and received healthy eating
and active lifestyles information. Families received two behavioural counselling sessions per
month covering healthy eating and physically active lifestyles.

The Nereu programme is led by the Ministry of Health and promoted in partnership with the
Ministry of Education and the Ministry of Sport. Main triggers for the programme were data
from the first National Nutritional Survey in 2004 that showed increasing levels of overweight
and obesity in Andorran children, the WHO overweight and obesity recommendations and the
2007 the national strategy for Nutrition, Sport and Health.

The health sector leads and coordinates the programme and is responsible for managing
user data, monitoring and evaluating the pilot phase and making necessary adjustments.
The NGO Associaciò Nereu will coordinate, monitor and supervise implementation. Dieticians
will provide counselling sessions to families in the programme. The Ministry of Education will
manage the sport extracurricular activities and report progress to all involved sectors. The State
Sport Secretariat has engaged sports clubs and informed sports facilities about the Nereu
programme. The Andorran School for Training on Sport and Mountain Professions will provide
sports counsellors for the extracurricular activities. The media has been involved through a
press conference presenting the programme and an interview on Andorran television.

An intersectoral committee was set up between the Ministry of Health, the Ministry of Education
and the Nereu Association and holds regular meetings. The Ministry of Education used its
intranet to keep internal stakeholders informed and a Nereu web-based platform was also set
up for coordination.

The Nereu programme brings primary health care benefits in terms of preventive action to
reduce obesity and increase physical activity and reduce NCD burden in the long term. While
the project is primarily funded from the Ministry of Health’s budget, physical activity sessions
are funded by the Ministry of Education.

The involvement of primary care professionals is essential for programme success. Their role
in the community as the first contact with the health care system and in identifying families
with children who could benefit from the Nereu programme is key.

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Main challenges or barriers encountered to programme performance are the work schedules
of families, many being employed in the tourism sector and having shift work schedules that
does not permit them to attend family counselling sessions. The existence of extracurricular
sports programmes, good working relationships with the Ministry of Education and their
willingness to take an active role in the programme have been facilitating factors.

The Nereu programme was very well perceived and accepted by the population at first, but
full family participation dropped possibly through fear of child stigmatization or work schedule
conflicts. The full involvement of primary care professionals in the project will help to improve
programme performance as they are the common thread that will link families with other
sectors and initiatives such as the Nereu programme.

The pilot programme ended in 2015. Full implementation of the programme will begin in
September–October 2016.

3. Armenia: National campaign to raise public awareness of AMR

The Ministry of Health of Armenia conducted a national campaign to raise public awareness
of AMR on 16–22 November 2015, coordinating efforts and support from a wide range of
stakeholders:

• other governmental agencies and public institutions, such as Drug and Medical Technology
Agency, NCDC Armenia, Food Security Agency, medical education institutions, public
hospitals and other health care providers;
• market actors such as mobile operators, pharmacies and companies working in the
agriculture and food production sectors; and
• mass media and civil society.

The ultimate goal of the campaign was behavioural change towards rational use of antibiotics
through raising awareness of AMR among the general population, health care providers,
pharmacists and veterinary service providers.

The campaign was planned under the National AMR Prevention Strategy, which was adopted
in 2015 but was triggered by the invitation from WHO to join the World Antibiotic Awareness
Week.

An inter(ministerial) board established by the Ministry of Health served as a coordination

mechanism. Four group leaders were identified to target specific audiences and use

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appropriate methods for information sharing or knowledge transfer. The board approved
common key messages and a campaign logo and oversaw campaign implementation.

Financial resources were not earmarked in the 2015 state budget; however, WHO provided
a grant of US$ 5000 for the production and dissemination of information on electronic and
printed media; and the Drug and Medical Technology Agency co-financed the campaign.

There was no formal mechanism for the evaluation of the campaign outcomes. However, the
results surpassed the expectations in terms of the interest and active involvement of private
actors and mass media, and in the feedback received from the population.

The main lessons learned (e.g. support from the private sector and the mechanism of
engagement) can be generalized in countries in the region with the same context and AMR
challenges. Other operational and organization experience gained during the campaign will
help to plan and implement the campaign more effectively in the future.

The country plans to conduct a further AMR awareness-raising campaign in 2016 based on
the lessons learnt.

4. Austria: Austrian health targets

In 2011, the Ministry of Health and the Federal Health Commission in Austria initiated a
widely participatory intersectoral process of preparation for national health targets in line with
an HiAP approach, with more than 40 key political and societal stakeholders. The general
public was consulted through an online platform. In 2012, the 10 national health targets
were adopted by the Council of Ministers and the Federal Health Commission. They are part
of the current government programme and represent a basis for health reform. Currently,
different intersectoral working groups work on each health target and define subtargets and
implementation actions; these will be monitored and evaluated by the Austrian Public Health
Institute. A clear implementation structure was set up in order to support the implementation
of the targets. The targets are based on a number of guiding principles. The most relevant are
focus on health determinants, a HiAP approach and promoting health equity. In addition they
relate to both living conditions and individual behavioural factors.

A broad governance approach is seen a key to generate joint ownership and to advance
health in general. The challenge, however, is to communicate the win–win situation to different
stakeholders and political players. At the beginning of the process, a policy dialogue was
organized and “motivational fact sheets” highlighting potential win–win situations of the health

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targets; policy priorities of the respective sector were produced for each ministry involved.
The intersectoral process and coordination is a priority for the Ministry of Health, with the
clear objective to keep the process moving and to offer a space for debate. In addition, the
Austrian Public Health Institute is supporting the process and its implementation. Plenum
(platform of more than 40 stakeholders) meets two to three times a year; different intersectoral
working groups meet several times a year to formulate subtargets, implementation actions
and indicators, while the leaders of all intersectoral working groups come together at least
twice a year to exchange experiences and lessons learnt, coordinate further steps and
enhance commitment. Each action has a focal point, with someone who is responsible for the
implementation. When a concrete action is defined within the intersectoral working groups, it
is crucial that the funding is secured. There is no joint budget for the process.

An intersectoral way of thinking/planning has been established. Furthermore the awareness

for health determinants, health equity and HiAP has greatly increased within different sectors.
Key lessons are that it is crucial to promote intersectoral cooperation, to empower relevant
stakeholders and to create ownership of the process. It is central to have a ministry leading
the process. By formulating a number of concrete actions and activities within (so far) five
national health targets, cooperation between sectors has become an intrinsic part of the whole
process. Challenges and barriers include resistance of old-fashioned/hierarchical structures,
keeping the momentum, finding the balance between a highly participatory approach and
leadership, lack of structures/processes regarding intersectoral cooperation with a focus on
HiAP in most of the Austrian provinces, and the challenge of ensuring common knowledge and
understanding with changes in plenum members. Capacity building (leadership, partnership,
organizational and workforce development, resource allocation) during the process and strong
leadership from the Ministry of Health have been major facilitating factors. Further facilitating
factors include strong political support; the participatory process, which fosters partnership
and commitment/ownership; a good combination of top-down and bottom-up approaches;
enough leeway to allow for creativity (no overregulation); and good team work.

5. Azerbaijan: National Strategy on NCD Prevention and Control

2013–2020

The President endorsed the National Strategy on NCD Prevention and Control in Azerbaijan
2015–2020 and the Operational Plan. Strategy preparation was preceded by a series of
studies conducted by the Public Health and Reform Centre of the Ministry of Health in 2008–
2011; these generated sufficient evidence for decision-making. Advocacy from WHO regional
and country offices was critical to initiate the national policy development on NCD prevention
and control.

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A working group composed of specialists from the Public Health and Reform Centre and the
Ministry of Health worked closely with the representatives of development partners (WHO,
the United States Agency for International Development and the World Bank) to draft the
strategy. The Ministry of Health submitted the draft strategy to the Cabinet of Ministers, and
the document was reviewed and endorsed by the relevant line ministries. Specialists from
the Public Health and Reform Centre carried out consultations with their colleagues at the
sectoral ministries to incorporate their feedback. Civil society and the private sector were not
engaged in the national policy development, which is common practice in Azerbaijan for the
development of national policies.

The strategy goal is defined as to “improve the health of the population in Azerbaijan, by
reducing premature mortality from noncommunicable diseases by 15% by 2020 through
integrated and collaborative interventions.”

Under objective 1, the national strategy envisages the establishment of a high-level national
intersectoral coordination mechanism for planning, guiding, monitoring and evaluating
enactment of the national policy, with the effective involvement of sectors outside health:
social, agriculture, finance, trade, transport, urban planning, education and recreation. Close
interaction with civil society and private sector as well as the mass media is intended for
raising awareness and for behavioural change interventions.

The Operational Plan provides a framework of results (outputs and outcomes) with indicators
and targets that will be used to assess achievements.

There is no dedicated budget for the implementation of the national strategy. The Ministry of
Health will be the main source of funding in the beginning; the line ministries have already
developed relevant sectoral work plans that will be translated into sectoral budgets in the
next budgetary cycle. Finally, the strategy objective 1.3 calls for ensuring “sustainable
financing and appropriate budgetary allocations to support equity-sensitive cost-effective
NCD interventions.”

6. Belgium: Response to Ebola crisis

The most widespread Ebola epidemic began in December 2013 in Guinea and continued
with significant loss of life for over two years. Since spring 2014, the Federal Public Service
for Public Health in Belgium provided information on Ebola virus and led consultations with
all concerned sectors, including the Federal Foreign Affairs, the Ministry of Defence, the
Scientific Institute of Public Health, the Federal Agency for the Safety of the Food Chain,

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Fedasil (federal agency for the reception of asylum seekers), SN Brussels Airlines, Brussels
Airport, the Port of Antwerp, the communities and regions, trade unions, customs, police
authorities, Institute of Tropical Medicine in Antwerp, Médecins sans Frontières, hospitals and
doctors, and so on.

In October 2014, a specialist in infectious diseases from the Antwerp Institute for Tropical
Medicine, Dr Erika Vlieghe, was appointed as Ebola coordinator. Dr Daniel Reynders from
within the Federal Public Health Services was named as her deputy. Dr Vlieghe drafted,
evaluated and fine-tuned a set of procedures in close consultation with all relevant departments
and institutions involved in the field and with the different regional authorities.

At every instance, Belgium tries to align its assistance to disasters as transversally as possible
across the disaster management cycle. The scope of its response to the Ebola outbreak
included research on vaccines; sending logistical support and means as well as provision of
a mobile laboratory in Guinea (blood tests to diagnose Ebola); continued flights by Brussels
Airlines to the affected countries; and support from Médecins sans Frontières and United
Nations Children’s Fund within the same framework (linked to laboratory activities in Guinea
and that notably aims to raise municipalities’ awareness and is linked to the construction of
communal medical centres).

Belgium has a complicated multilevel political and administrative structure: the Federal
Services of Public Health, Food Chain Safety and Environment; the Agency for Care and
Health of the Flemish Community; the Common Community Commission of Brussels-Capital;
the Walloon Region; the German-speaking Community.

The Ministry of Interior hosts the Governmental Coordination and Crisis Centre, a 24-hour
operational centre that provides infrastructure, interdepartmental management, expertise
and coordination. The first national meeting on Ebola was held the Crisis Centre in October
2014 and brought together interior, public health, transport and mobility, defence, police and
foreign affairs officials and all levels of government.

The Federal Ministry of Health’s response was led by their Public Health Crisis Centre, which
was expanded from five people to 25 and an Ebola Crisis Centre established.

In addition to liaising with health care institutions and professionals at all levels of government,
the Ebola coordination cell cooperated with NGOs on the drafting of the national plan, training
sessions, follow-up of returning humanitarian health workers and scientific contributions.
There was also engagement with the private sector on procurement of materials (e.g. cleaning
equipment).

The Belgian government allocated up to €40 million for the response to the Ebola crisis.

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Belgium held a national conference to evaluate the response to the Ebola crisis and to integrate
lessons from the peer-learning delegation of the European Centre for Disease Prevention
and Control. This peer review praised good collaboration across government and welcomed
the concise arrangements for the organization and governance of the Ebola response. It also
highlighted the intensive collaboration between key stakeholders, including clear coordination
and collaboration with organizations outside the health sector. This resulted in guidelines and
standard operating procedures being drafted or amended with contributions from professional
experts, scientific collaborators and NGOs.

The Ebola crisis identified that expert resources (scientists, communicators, medical
specialists) were available but the existing workload would make it difficult to respond
effectively at primary, secondary or tertiary levels of health care if more than one person with
Ebola infection needed to be treated. To build on the legacy of the Ebola crisis response,
generic preparedness and response plans are being strengthened and updated.

7. Bosnia and Herzegovina: Mental health services at community

level

Mental health gained prominence as a public health issue on the international agenda during
the last decade of the twentieth century. There was growing consensus that major reforms
were needed, including a shift to community-based care. WHO strongly advocated this new
approach, dedicating the 2001 World Health Report to mental health (1).

In general terms, this involves a greater focus on care near where people live, care that
enhances recovery and care that is based on the evidence of what works best; this requires
the involvement of multiple services through engagement of a number of sectors in ensuring
coordinated care.

Intersectoral action of improvement of mental health at community level in Bosnia and

Herzegovina is part of the long-term continuing commitment of the health authorities in Bosnia
and Herzegovina and the ministers of health in the South-eastern Europe Health Network to
continue with the process of mental health reform in the region.

The overall strategic goal of this intersectoral action is to improve mental health of the population
in the countries of south-eastern Europe as well as to increase respect for the human rights and
dignity of persons with mental disorders. Specific objective is provision of integrated community-
based mental health services with greater focus on care near where people live, care that
enhances recovery and care that is based on the evidence of what works best.

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The intersectoral action was initiated in 2002 as a result of the 2001 World Health Report
dedicated to mental health and as commitment to the regional development of health and
well-being within the South-eastern Europe Health Network. The action was oriented to
providing integrated mental health care through community-based centres; the initial stage
was piloted at two centres, with growing network of centres throughout the country.

Beyond the initial two-year period of activities implemented with donor assistance, success
led to continuation for an additional four years; thereafter, the commitment and political will,
jointly with the dedication of the public health professional community, local government units
and civil society, have ensured that this initiative is a long-standing one, remaining active and
contributing to the health and well-being of citizens.

8. Croatia: Intersectoral Committee on Environment and Health

Health is more than just the health sector itself; the complexity of factors influencing this public
good requires intersectoral action in which multiple sectors join their expertise, capacities and
resources in effective, efficient, timely and consistent provision of services to the citizens.

One such example of intersectoral action is the initiative of the Croatian Ministry of Health
to establish an intersectoral committee for environment and health, which would cover
the dimensions of health and well-being particularly with regard to issues related to the
environment, in line with ample evidence of the effect of environmental factors and conditions
on health and well-being.

In 2014, Ministry of Health of Croatia established the Intersectoral Committee on Environment

and Health; this involved health, environment and science sectors, alongside related agencies
in these sectors, to assist with issues of environmental health and any other expertise requested
by the Ministry of Health or other higher governance structures, such as the parliament.

The successes of the Committee are predominantly in the area of policy advice to the
Minister of Health; however, because the Committee has only recently been established,
other functions have not yet been established: monitoring is planned to measure the level of
achievement of the objectives set for the work of the Committee, as well as for the Ministry
of Health programme.

Some of the key assets to the initiative are the political will and commitment to address
issues of intersectoral nature in an intersectoral manner, although political changes may well
affect the process. The initiative has encouraged other sectors to initiate joint programmes

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and intersectoral actions, both at national and local levels, and has served as a matrix for
comprehensive and timely intersectoral collaboration, which is so important for the holistic
improvement and promotion of health and well-being in Croatia, and possibly in other
countries.

9. Cyprus: National Strategy and Action Plan to Fight Sexual

Abuse, Exploitation of Children and Child Pornography 2016–2019

Child sexual abuse is a problem worldwide and that persists in the WHO European Region.
Analyses of community surveys from Europe and around the world have estimated a
prevalence rate for sexual abuse of 9.6% (13.4% in girls and 5.7% in boys). Child sexual
abuse, exploitation and child pornography is also an issue of concern to Cyprus. In 2015, the
Cypriot Council of Ministers decided to tackle this issue by establishing an ad hoc ministerial
committee with Ministers of Labour, Education, Health and Justice to coordinate preparation
of a National Strategy and Action Plan to Fight Sexual Abuse, Exploitation of Children and
Child Pornography.

The Strategy’s goal is to protect children in Cyprus from all forms of sexual abuse, exploitation
and pornography. The initiative received high-level political commitment and was triggered
by the need to enforce existing legislation (2014) based on the Lanzarote Convention.
Intersectoral action was chosen to ensure coordination with regard to addressing specific
cases as well as for application of a coherent, systematic approach to dealing with the issue.
The media broke the silence and raised awareness among the public. This coupled with the
introduction of the new law supported by the ongoing “ONE in FIVE” campaign provided
momentum for action.

The Ministry of Labour took the lead since social issues fall under its mandate. The Ministry
of Health provided technical expertise and assumed an advisory role providing the scientific
evidence. Within the context of strategy development, the Ministry of Justice and Public Order
ensured that a specialized police group would be educated on how to conduct video-recorded
statements investigate sexual violence offences against children according to location (rural or
urban). The Ministry of Education offered seminars in schools for teachers on sex education,
prevention of sexual abuse, diversity in school, anti-racist policies and actions, sexual and
reproductive health of adolescents and other topics. NGOs put pressure on the Government
to act on this issue, prepared the National Strategy’s Action Plan and provided funding. The
private sector, psychologists and social workers offered their specialized services. The media
ensured wide coverage of the issue throughout.

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Information sharing came naturally through enforcement of existing legislation. Parliament

encouraged sectors to work towards a single strategic plan. Parliamentary hearings facilitated
the process. Bureaucracy-free working and open communication facilitated the intersectoral
working group’s job.

The main financial leader of the initiative is the Government of Cyprus. The Hope for Children
NGO provided €300 000 for the project and a house for the victims. This programme has led
to better links and collaboration being established with other sectors.

Creation of an intersectoral working group with accountability for the plan and open
communication were the keys to success. Initial resistance to intersectoral working and
“thinking out of the box” was overcome once work began. The small size of the country, and
thus proximity, made for easy dissemination of information. Existing legislation meant that a
legal framework was available to build upon, with international commitments supporting this.
Support from NGOs and private practitioners by means of funding and person time were also
key enablers.

Health of all children in Cyprus and future psychological well-being, as a human right, is
the foundation for this plan and its strategic goals. Wide sector involvement, including a
strong NGO presence and media pressure, helped to develop the best plan for the benefit of
children. Cyprus has recorded significant achievements in the fight against sexual abuse and
sexual exploitation of children since 2014 as a result of this well-coordinated effort.

The National Strategy and Action Plan were approved in March 2016 by the Ministerial
Council.

10. Czech Republic: Action plans for implementation of Health

2020: National Strategy for Health Protection, Promotion and
Disease Prevention

The Health 2020 National Strategy for Health Protection, Promotion and Disease Prevention
adopted in 2014 is an umbrella document for the Czech Government, with key priorities
in those areas and for the development of an integrated people-centred health system.
A set of horizontal targets defines specific areas in which action can be taken jointly with
other sectors to target the main causes of ill health and deaths in the population. Equally
important are the vertical targets, primarily the improvement of health literacy and reduction
of health inequalities. These need to be taken into account across all measures in order to
strengthening the role of individuals and communities in taking care of their own health. The

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Strategy also aims to develop the public health system for the long term and to stabilize a
system of disease prevention, health protection and promotion.

Action plans are the implementation tool for the Strategy. A working group was established for
each action plan and relevant stakeholders, including nongovernmental actors, were invited.
Their contributions ensured that the strategy remained impartial. Dialogue has started with
all government departments and representatives of non-profit-making and private sectors,
scientific and research institutions, professional associations and other stakeholders in order to
prioritize actions in the action plans and start implementing projects. Significant considerations
have been undertaken in order to secure effective implementation of the action plans, which
include different tools and mechanisms for effective health promotion, primary prevention and
health literacy improvement. The action plans are at interministerial level and are coordinated
by the Government Council for Health and Environment. A managing committee has been
established at the Ministry of Health that is mandated with preparation and coordination of
implementation of action plans according to strategic objectives and priority areas.

Government Resolution 671 supporting the implementation process of action plans was
adopted on 20 August 2015. The Parliament of the Czech Republic, Chamber of Deputies,
adopted Resolution of Committee on Health No. 99 on 2 September 2015. The action plans
were prepared with the broad participation of the general and professional public. The working
groups for preparation, implementation and evaluation consisted of various stakeholders. The
managing committee consists of deputy ministers from different departments of the Ministry
of Health. The working groups’ members include stakeholders from various departments/
ministries.

The implementation of the action plans is a work in progress and, therefore, it is too soon
to judge the lessons learnt. However, at this point, it is clear that political support played a
key role in the process of preparation of the strategy and the action plans as implementation
tools. A strong focus on implementation from the beginning was important in engaging a wide
range of stakeholders and the general public.

11. Denmark: Intersectoral action for health at the municipal level:

implementing health promotion packages

In the structural reform of 2007, municipalities in Denmark were delegated the responsibility
of health promotion in accordance with the Health Act of 2005. The main goals of the reform
were to improve the welfare of citizens, to bring decision-making on health closer to the
citizens and to integrate health with other policy areas at the municipal level, thus saving

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costs related to health promotion. Since then, many municipalities have adopted intersectoral
policies to promote health and well-being. Although municipalities have independently
adopted and implemented these policies, some national level guidance has been created to
support these efforts.

The “health promotion packages”, introduced by the Danish Health Authority in 2012, are an
example of national level guidance created for supporting health promotion and intersectoral
action at the municipal level. These packages comprise an evidence-informed tool to assist
municipal decision-makers and health planners in setting priorities, planning and organizing
local health promotion initiatives. The 11 packages – focusing on different risk factor areas
such as alcohol, tobacco and physical activity – aim to contribute to municipalities’ efforts to
work across administrative sectors and to integrate health into all municipal policies. A study
by the University of Southern Denmark on the health promotion packages in 2015 found that,
in the absence of (numerical) evidence of the effectiveness of intersectoral action for health,
having knowledge-based guidelines emanating from the national level can create legitimacy
for municipal intersectoral action for health. Although the health promotion packages have
been criticized as being rather vague and abstract (lacking specific guidance on topics), they
were found to have functioned well for the health sector for the purpose of initiating dialogue
with other sectors. Support from national level institutions or organizations was seen as a clear
facilitating factor for local level intersectoral action for health. Local Government Denmark
(association of the 98 Danish municipalities) has also supported intersectoral initiatives at the
municipal level.

Support may also be offered in the form of funding. Although not described in detail in this
study, the central Danish Government has created incentives for intersectoral action by
offering some funding for specific, temporary intersectoral projects at the municipal level.
Public–private partnerships are also encouraged through the “partnership initiative for health
promotion” where funding is available for intersectoral projects. Some municipalities have
also increased incentives for intersectoral action for health through establishing joint funding
for intersectoral initiatives. Public participation has been organized at the local level through
public dialogue hearings and, in some cases, through web-based feedback opportunities.

Although progress has been made and intersectoral action is generally better recognized in
Denmark, several challenges remain. More thought needs to be given to the role of the health
sector in intersectoral action for health – it may not always be the best leader. Moreover,
specific capacity-building activities would be needed to support the implementation of existing
guidelines and recommendations. This case story demonstrates that, although municipalities
offer an excellent arena for intersectoral action, particularly because they are closer to the
citizen, such efforts at the local level benefit from national level guidance and support. The
Danish health promotion packages and other tools are an excellent example of such support.

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12. Estonia: National Health Plan 2009–2020

The National Health Plan is an intersectoral, long-term strategy, which aims to improve health
adjusted life expectancy of Estonians. It is established by a government regulation, and its
actions are mandated by different legislative decrees. The Plan details five thematic fields:
increasing of social cohesion and equal opportunities, ensuring healthy and safe development
for children, shaping an environment supporting health, facilitating a healthy lifestyle and
ensuring the sustainability of the health care system. It highlights that the right to protect
one’s health is one of the basic human rights, and that everyone must have a possibility to
live in a healthy environment with the opportunity to make healthy choices. Common values
such as joint responsibility for health, equal opportunities and justice, social inclusion, and
increasing power of civil society are priorities.

The National Health Plan is implemented at national, regional and local level, and its
progress is monitored by an intersectoral structure, the Steering Committee, which includes
representatives from all relevant ministries and departments, semi-governmental agencies
and the civil society. The Ministry of Social Affairs leads the Steering Committee and acts as
its Secretariat, coordinating its implementation. The activities of the Plan are funded from the
state budget. The yearly progress reports are opened for public feedback in an online portal
(eelnoud.valitsus.ee) – an excellent example of how public participation can be organized.
Another good practice of the Plan is that regular overviews of activities are conducted, and
clear indicators, baselines and targets related to risk factors and health outcomes are set,
monitored on a yearly basis and reviewed every four years. Having such data may facilitate
communication with other sectors. An evaluation of Plan implementation (2009–2015) is also
to occur.

Lack of human and financial resources is still a challenge for implementation of the National
Health Plan. Lack of high-level awareness and political will on HiAP was also seen as a
challenge to collaboration between sectors. The fact that the Plan is mandated by legislation
was highlighted as a facilitating factor. The intersectoral Steering Committee offers a forum
for discussion of issues of common interest, and it operates within clearly set, measurable
targets. As its activities are also open for public review, it is a good example of a national
intersectoral body that is accountable, transparent and has the potential to foster ownership
of intersectoral action across sectors, including civil society.

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13. Finland: Health in all policies (approach)

Intersectoral action for health initiatives have been implemented in Finland since the
1970s and have been strongly impacted by international milestones, such as the Alma-
Ata Declaration in 1978 (4) and the Ottawa Charter in 1986 (6). Initially, this approach was
taken as a response to apparent health inequities and poor overall health in the country. The
concept and approach have been developed over decades, in collaboration with WHO. The
term “health in all policies” was first used in 2006 when Finland adopted it as a theme during
its EU presidency.

HiAP is a long-term approach that aims to ensure that health and well-being are taken into
account in the policies and actions of all sectors, at all levels of governance. Gender, equity
and human rights considerations are central in this approach. In Finland, the Constitution,
the Public Health Act, and the Health Care Act mandate HiAP at the municipal level. At the
national level, action is coordinated by the Ministry of Social Affairs and Health. The Advisory
Board for Public Health is an intersectoral national level body that aims to promote health and
well-being, including HiAP. Ministries, local authorities and the civil society are represented
on the Board. Other mechanisms that have been used to support HiAP include human impact
assessment, networks of HiAP focal points in all ministries and various intersectoral working
groups such as the National Board for Nutrition.

Although HiAP has gained recognition and has been increasingly accepted as an approach
in Finland, there are still challenges in its implementation. For example, lack of resources
for HiAP is an issue, and approaching other sectors with health arguments has remained
challenging. Capacity for advocacy still needs to be built. In terms of terminology, “well-being
and health” has been increasingly used instead of simply the word health. Moreover, lack
of a broad approach to health in education impedes HiAP work. This is particularly true for
education of doctors and other health professionals, which has remained too focused on
health care.

Given that Finland had a long history in HiAP and intersectoral action for health implementation,
many lessons learnt can be drawn from its experience. For example, laws that obligate
intersectoral action have worked well in Finland and have been considered a facilitating factor
in mandating sector collaboration. Institutions that support HiAP are key to success. In Finland,
the National Institute for Health and Welfare has been strong in promoting HiAP, for example
by developing supportive tools such as a model for municipalities for “reporting for well-being”,
a human impact assessment and the TEA-viisari online service, which enables follow-up
of municipal HiAP activities. Municipalities have successfully used existing structures, such
as the Healthy Cities programme, to initiate HiAP. Most importantly, the Finnish experience

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demonstrates that HiAP is a systematic, long-term approach. It requires long-term vision,

commitment and permanent structures to be effective.

14. France: Improving the health of school-age children

Each ministry in France has a senior official designated as the nominated contact person
for health. Intersectoral action in health has a long history in France: for example agriculture
and health departments (French National Nutrition and Health Programme since 2001), and
education and health departments (Health Education Programme 2011–2015). The 2014
Health Act established a new mechanism, an Interministerial Committee for Health, to be
chaired by the Prime Minister and bringing together all of the relevant departments (whole of
government). The Committee has not yet been convened but a first meeting is due in 2016
on the topic of AMR.

The Ministry of Health promotes a “health democracy” concept, with health stakeholders
invited to co-create public health policy at all levels. This is not yet a whole-of-government
approach because it is initially designed to create closer relationships between the regional
health agencies and local authorities.

Most ministries have representatives in the regions who are accountable to the prefect,
the Prime Minister’s representative at regional level. Three ministries (education, health
and justice) have their own territorial configurations who do not report to the prefect. The
Department of Health works through regional health agencies. There are also regional public
policy coordination commissions that include all public entities with an impact on health, such
as local branches of health insurers.

As part of the intersectoral activities for health in school-aged children, there are some shared
budget mechanisms; for example, the Ministries of Agriculture and Health co-finance activities
related to obesity prevention in children.

A new concept of the parcours éducatif de santé or educational pathway of health is designed
to support well-being in schools. The Ministry of Health sets the child health goals and the
Ministry of Education is responsible for the health outcomes.

It has been challenging to get other ministries involved. There are legal agreements between
Departments of Health, Education, and Social Affairs and this makes collaboration easier.

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15. Georgia: Tobacco control: whole-of-government approach

The Government of Georgia established the State Committee on Tobacco Control to strengthen
tobacco control interventions and, to ensure the effective implementation of the respective
law on 15 March 2013. The Committee is chaired by the Prime Minister, and its Deputy
Chairperson is the Minister of Labour, Health and Social Affairs. This intersectoral Committee
unites the key decision-makers from the Ministries of Education and Science, Justice, Internal
Affairs, Sport and Youth Affairs, Finance, Economy and Sustainable Development, Regional
Development and Infrastructure, and Agriculture, plus with the members of the Parliament
(the Patriarchy), mass media, the Georgian Public Broadcaster, and relevant international
and local NGOs. The National Centre for Disease Control and Public Health serves as the
Secretariat of the Committee.

The Tobacco Control National Strategy and the Action Plan 2013–2018 were developed by
the working group of the Committee and further approved by the Government of Georgia on
30 July 2013 (Strategy) and 29 November 2013 (Action Plan). The process was continued
with elaboration of amendments to the five relevant laws (Administrative Offences Code of
Georgia, Tobacco Control Law of Georgia, Law on Advertisement of Georgia, Broadcasting
Law of Georgia and Tax Code of Georgia). Approval and mainstreaming of these amendments
are expected shortly.

The Tobacco Control National Action Plan includes measures aligned with the Framework
Convention on Tobacco Control, with a focus on the prevention of smoking among young
people. This includes a comprehensive ban on tobacco advertisement, promotion and
sponsorship; an educational campaigns on tobacco-related harm that is run within the
secondary and graduate education systems; strengthening the penalty mechanism for selling
tobacco to minors or near educational facilities; awareness-raising campaigns in collaboration
with the Ministry of Sport and Youth, the Georgian Public Broadcaster and other relevant
agencies; annual increases in tobacco taxation; and enforcement of a partial smoking ban in
public premises with preparation for a total ban after 2015.

Bilateral cooperation mechanisms were also used between the health and finance sectors in
order to strengthen specific policies such as tobacco taxation.

The national Health Promotion Programme is used as a major financing source but a funding
gap within joint financing from different sectors still needs to be addressed. International
assistance mechanisms have contributed significantly to the attainment of the national
strategy goals through intersectoral approach.

There is close collaboration with media in order to ensure transparency of the process.

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16. Germany: AMR strategies (DART 1 and 2)

AMR has become an important issue in Germany, moving from a regional to national priority
and then championed globally during Germany’s leadership of the G7. This prioritization
is driven by data. In 2006, more than 40 000 people died because of an infection. Death
rates rose by 14% between 2002 and 2006. Hospital-acquired infections are a particular
challenge; rates of methicillin-resistant Staphylococcus aureus (MRSA) have increased from
2% to approximately 23% in a 10-year period. However, in neighbouring countries such as
the Netherlands and Scandinavia, MRSA rates remain below 5%.

A pilot project EUREGIO MRSA-net, financed with EU funds, in the Dutch–German border
region Twente/Münsterland sought to improve the implementation of MRSA prevention and
control strategies by exchanging knowledge and technology. The EUREGIO model was
promoted by a decision of the regional ministers of health and recommended as a model for
regional networks on AMR, which now exist in almost all German states.

In 2008, the first national AMR strategy (DART) was published jointly by the Federal Ministry
of Health, the Federal Ministry of Food and Agriculture and the Federal Ministry of Education
and Research. The strategy has 10 core goals with actions, actors and milestones identified
for each goal. A total of 42 interconnected actions were set out.

In 2015, an updated strategy, DART 2020, was published with an explicit focus on a “One
Health” approach encompassing human and animal health. DART 2020 sets out six objectives
that apply equally to human and veterinary medicine and should be implemented appropriately
in both contexts (see Case story 9). This second strategy is shorter and more political.

The role of the media in raising public awareness about AMR has been critical to maintaining
political will. Tackling AMR effectively will also require a shift in the mindset of consumers.
Improving the conditions for animals and using fewer antimicrobial agents in veterinary
practice requires fewer animals to be in the food chain, consumers to eat less meat and pay
more for it.

DART was drafted by the Ministry of Health after interviews with a range of experts that
identified gaps. It was also subject to extensive public consultations and featured separate
aims for human and animal health sectors. By DART 2 there were joint aims under the “One
Health” banner. This represented a step change in terms of integrated working. Civil servants
stopped thinking in terms of “silo budgets” to find ways to do more than before and scale up
their activities.

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Precise, measurable indicators linkable to project activities are useful, for example rates of
resistant bacteria in blood cultures. After a decade of efforts, the levels of resistant bacteria
in blood culture show a significant decline in 2014. Pilot projects can test out approaches that
generate the evidence to convince politicians to scale up activities.

The process of building working relationships between the federal ministries was slow and
sometimes challenging to bring different actors together. One useful lesson has been to
inform people early, keep them close to the process and involved them in the follow-up. Each
ministry has now designated contact people for the DART strategy.

Efforts to combat AMR are a natural choice for intersectoral action because of the key
connection between human and animal health. Three ministries were initially involved, health,
agriculture and research, and these were joined by environmental health.

The sustainability of the efforts to tackle AMR is uncertain. Local public health officers are
needed for quality audit in hospitals. Funds are needed to train medical professionals and to
ensure a good ratio of staff to patients in intensive care environments, which are key sites for
infection. This is largely a financial issue but is critical for prevention and quality assurance.

17. Hungary: Comprehensive health promotion in schools

The 2011 modification of the Act on Healthcare set the background for comprehensive health
promotion in schools. High priorities were the diseases affecting young people, disease
prevention and health promotion, raising awareness of health issues among the Hungarian
population as a whole and implementation of regular screening programmes for specific age
groups. The Act outlined comprehensive health promotion in schools with the aim of ensuring
that all children participate in health-promoting activities that would effectively improve physical
and mental health and their well-being. The key action points included healthy diet, daily
physical education, physical activity, physical and mental health development, prevention of
behavioural dependencies and consumption of products causing dependency, prevention
of school violence, and personal hygiene. The schools cooperated with the school health
service to develop and implement local health promotion programmes. Adoption of relevant
legislation was the first step towards the goals of comprehensive health promotion. In order to
support implementation of these goals, three EU-funded projects were launched. The initiative
was triggered by the launch of “Healthy Nation – National Public Health Programme” in 2001
and further supported by the decisions of the Public Health Interministerial Board in 2003.

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School health promotion is seen as an intersectoral responsibility, not just one for the health
sector. Comprehensive health promotion is, therefore, a shared goal between the Departments
of Health, Sport, and Education. Support from the prime minister has been very important for
the promotion of daily physical education. The organization of the Ministry of Human Capacities,
which is responsible for health, education, sport, higher education, youth and family, social
integration, culture, church and civil society, provides at present an important intersectoral
mechanism for joint action since it brings often conflicting governmental sectors under the same
roof. Effective intersectoral coordination was secured by involvement of all key players.

The achievement of co-benefits has been considered from the viewpoint of different sectors.
For the health sector, it was most important to secure primary prevention of most NCDs and
better physical and mental health for all children. For the education sector, better health for
all children has been seen as prerequisite for better academic achievements, more effective
work for teachers, less absenteeism and less aggression. For the sport sector, fit and healthy
children had better chances in junior education and competitive sports. Higher education
connected better health with better academic achievements. Social integration has been a
concern with children from the most disadvantaged groups, who have worse socioeconomic
background and may have a poorer health status; these children can easily be reached in
school. Comprehensive health promotion aims at better health and equal opportunity for all
children. The culture sector has seen art classes at school as significant factor in the mental
health promotion of the children.

There were several NGOs involved in the process. Long-term and stable commitment in
the health sector from 2001 onwards was the most important facilitating factor. Long-term
and persistent civil work from the medical societies, in good cooperation with the NGO’s
representing teachers, was the second most important.

Based on the legislation adopted in 2011 and on its gradual implementation, all pupils do
have physical education classes every day from the academic year 2015/2016, which equals
five sessions of 45 minutes of physical education a week.

18. Iceland: Establishment of a Ministerial Council on Public

Health: a public health milestone for Iceland

Iceland faces demographic changes and other major challenges that call for effective solutions
to preserve and improve health and well-being at all life stages. One of the priorities of the
current coalition government’s (2013–2017) platform is to ensure equality for all citizens by
means of public health and preventive measures. In 2014, the Prime Minister of Iceland

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established, with the approval of the Government, the Ministerial Council on Public Health.
The main role of the Council is to promote dialogue and cooperation between ministers and
ministries, harmonize overlapping thematic areas and prepare a comprehensive public health
policy and action plan for submission to the Government.

Through intersectoral work, the Council aims to improve health, well-being and equity at all
stages of life, with special emphasis on children and adolescents. To reach these goals, a
comprehensive public health policy and action plan will be published in 2016. One of the
actions in the plan’s draft is implementation of a health-promoting community project in all
communities in Iceland. This project will assist communities at the local level to work across
sectors to create environments that promote the health and well-being of all inhabitants,
emphasizing HiAP.

The Ministerial Council comprises the Prime Minister (chairperson), the Minister of Health,
the Minister of Education and Culture and the Minister of Social Affairs and Housing plus
representatives from their ministries. A Public Health Committee, also established in 2014
under the authority of the Minister of Health, also involves stakeholders from a wide range of
sectors. The Committee’s main role is to advise and support the work of the Ministerial Council
by drafting the public health policy and action plan and consulting regularly with the Council.
Apart from the sectors represented in the Ministerial Council, the Public Health Committee
engages representatives from unions, public health centres, universities and associations.

Participatory mechanisms have brought together stakeholders from different sectors through
the work of the Ministerial Council and the Public Health Committee, thereby facilitating
communication, joint understanding and a sense of ownership among those involved; all
stakeholders in the Public Health Committee were invited to contribute to the draft strategy.
The Ministerial Council of Public Health has earmarked funding from the state budget for the
health-promoting community projects in 2016. An evaluation plan is included in the Public
Health Strategy and some suggested actions are being assessed.

Lessons learnt emphasize the importance of using language and concepts that everyone can
relate to. Work should be founded on a common ground and understanding so that everyone
can see the benefits of participating and contributing. Being able to show other sectors how
public health, well-being and reduced health inequalities are also important and relevant to
their needs and helps them to reach their goals and facilitates the work of the Ministerial
Council. Challenges relate to limited resources, such as time, human resources and funding.
To ensure sustainability of this work, it is essential to maintain its continuity despite possible
changes in government at national and/or local level.

The establishment of the Ministerial Council is an important milestone for public health work
in Iceland, bringing together ministers from different sectors to find common ground to work
towards improved health, well-being and equity.

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The Ministerial Council is currently in place and working on the comprehensive health policy
and action plan. They have discussed, among other things, determinants of health, HiAP,
health tourism, a comprehensive public health policy, an action plan to improve public health
in all age groups with a special focus on young people, and public health indicators.

19. Ireland: Healthy Ireland

The Healthy Ireland framework for improved health and well-being 2013–2025 is a strategy
based on the determinants of health. Inspired by Health 2020, it has four central goals.

• increasing the proportion of people who are healthy at all stages of life;
• reducing health inequalities;
• protecting the public from threats to health and well-being; and
• creating an environment where every individual and sector of society can play their part in
achieving a healthy Ireland.

Healthy Ireland sets out a framework of 64 actions for public and private sector organizations,
communities and individuals across six themes:

• governance and policy

• partnerships and cross-sectoral working
• empowering people and communities
• health and health reform
• research and evidence
• monitoring, reporting and evaluation.

The Healthy Ireland framework draws on existing policies but proposes new arrangements to
“ensure effective cooperation and collaboration and to implement evidence-based policies at
government, sectoral, community and local levels”.

Implementation of the actions will be managed through an outcomes framework, with key
indicators such as health status, weight, diet and activity levels plus measurable targets.
Health inequalities measures and the broader determinants of health will be assessed, such
as the proportion of young people completing second-level education, access to green spaces
and indicators measuring the extent to which the population’s health is protected (e.g. uptake
of immunization programmes).

The changing demographics of Ireland was the trigger for the initiative. Life expectancy had

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increased but overall health status had not. A growing population of older people will also
result in a higher chronic disease burden with associated costs.

The Health Service Executive recently published its implementation plan for Healthy Ireland
in the Health Services with three priorities: reforming the health system, reducing chronic
disease and improved staff well-being.

A choice was made to create few new structures that need servicing. The Cabinet Committee
on Social Policy and Public Sector Reform (chaired by the Taoiseach (Prime Minister)) has
responsibility for overseeing implementation. A cross-sectoral group comprised senior officials
from government departments and relevant national agencies. External stakeholders are
convened via the Healthy Ireland Council, a platform to connect and mobilize communities,
families and individuals.

The focus is on implementation science and building cross-sectoral relationships and links
to develop an enabling environment for collaborative implementation. The goal is cultural
change, operational change and mind-set change so that health and well-being is on
everyone’s agenda in a meaningful way.

The Healthy Ireland framework has political support at the highest level of the Irish Government
but it is too early to evaluate progress. The long-term time scale of the initiative (to 2025) gives
time for governance processes to mature and the activities to bear fruit. In 2015, a baseline
survey of more than 10 000 people was made and annual surveys will continue.

20. Israel: A government decision to promote a healthy and active

lifestyle

In December 2011, Israel launched the National Programme to Promote Active, Healthy
Lifestyle, an interministerial and intersectoral effort to address obesity and its contribution to
the country’s burden of chronic disease.

The initiative was triggered by ample evidence of rapidly increasing rates of obesity among
Israelis, and it was further supported by existing research on the correlation between obesity
and NCDs, which were also increasing in incidence in the country; rates of diabetes mellitus
are twice as high as the average in western Europe, and the number with hypertension has
increased by more than 250% in 25 years.

Pressure from the expert community and the political will of high officials, channelled
through the Healthy Israel 2020 policy adopted in 2008, have led to the establishment of an

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intersectoral policy and implementation mechanism that involves the health, education and
agriculture sectors and will be extended to other sectors including the Ministry of Finance,
local governance units and health management organizations. The initiative consists of joint
efforts to limit access to unhealthy food in schools and to promote healthy school meals and
physical activity. The success of the initiative is indicated by evaluations that have shown
obesity levels stabilizing at a plateau; and in coming years it is expected that the desired
outcome of reduced obesity will be observed.

Changes in government and achieving stable financing have been challenges, but the
continuation of the initiative shows unanimous commitment to reaching this universal goal.

This case study exemplifies intersectoral action including joint planning, implementation
and, to a limited extent, budgeting between the Ministries of Health, Agriculture, Education
and Culture, and Sport, reflecting the Health 2020 and HiAP approaches through integrating
health into the policy-making of other sectors and line ministries.

21. Latvia: Advisory Council for Maternal and Child Health:

intersectoral action with civil society

The Advisory Council for Maternal and Child Health is a permanent intersectoral body
that engages various stakeholders including professional associations and NGOs in the
development and implementation of mother and child health policy in Latvia. The Advisory
Council was established by regulation of the Ministry of Health in 2008 with the aims of
decreasing maternal and infant mortality and facilitating the exchange of information and
cooperation between the Ministry of Health, NGOs and state and local government institutions
in this field. It has 18 members, and its work is coordinated by the Department of Health
Care of the Ministry of Health. The head of the Advisory Council is the main specialist of the
Ministry of Health on maternal and child health issues.

The Advisory Council offers an arena for the civil society to participate in maternal and child
health policy planning and implementation at the national level. The sector collaboration is
primarily vertical (i.e. between the Ministry of Health, associations representing local and
regional governments, and NGOs). The Advisory Council’s meetings are also open to the
public, and information about the Council’s meeting is available on the Ministry’s website (in
Latvian). Questions and proposals for the Council may also be sent via the website.

Although sector collaboration in the area of maternal and child health has improved in
Latvia, challenges remain. For example, engagement of some sectors has been easier than

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others. Tools are needed, for example for negotiating or communicating financial implications
(including savings) related to intersectoral action.

Regarding the facilitating factors, ownership was improved by engaging NGOs from the
beginning and ensuring that they participate as full members of the Advisory Council (‘NGOs feel
like they are a part of the political process’). In offering a platform for civil society participation,
the Advisory Council is also a good example of a mechanism through which bottom-up input
for national initiatives can be ensured and government accountability improved.

22. Lithuania: State Health Affairs Commission

The State Health Affairs Commission is a permanent intersectoral structure that was establish
in 1996. It is responsible for health promotion, including the promotion of HiAP in Lithuania.
It is chaired by the Minister of Health and has 21 members, representing all ministries and
one NGO. The activity of the Commission has been revived since 2013. The Commission is
an institution coordinating the planning of health policy measures and the implementation
of these at the ministries and other government institutions, as well as implementation of
the laws and other legal acts on health activities. Promotion of HiAP is a key strategic goal.
Equity, gender and human rights issues are discussed at the Commission but they are not
explicitly in its mandate.

There has been widespread acknowledgement that the health sector alone cannot take
care of health and well-being of the population. Even though other sectors have increasingly
participated in the work of the Commission, it has been somewhat challenging to “make
other sectors actors, not spectators”. There have also been some political barriers and it
has been challenging at times to gather together vice-ministers, who are members of the
Commission. Political changes are also difficult; changes of ministers may impact the agenda
of the Commission. Against this, the high participation of high-level politicians has made it
easier to take decisions and to implement intersectoral policies. Furthermore, participation of
vice-ministers in the Commission has meant that politicians have become overall more aware
of health issues. This high-level participation in the Commission has, therefore, increased the
legitimacy of intersectoral action for health.

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23. Luxembourg: Get moving and eat healthier! A decade of

intersectoral action to reduce obesity in Luxembourg

According to the 2013–2014 Health Behaviour in School-aged Children survey data for
Luxembourg, 26% of boys and 14% of girls aged 11 years are overweight or obese. Data
from the national medical school surveillance system (2014/2015 school year) showed that
14.1% of boys and 14.3% of girls in primary schools are overweight or obese. Growing levels
of overweight and obesity in Luxembourg triggered action to:

• increase awareness among the population and provide information on the importance of
healthy lifestyles for physical, mental and social health;
• promote balanced nutrition; and
• increase the quantity and quality of physical activity in the population, including children
and adolescents.

This case story describes a project and a national strategy, called “Gesond iessen, mei
bewgen” (healthy diet, more movement), on increasing physical activity and promoting
balanced diets for all residents of Luxembourg that was launched in 2006 and is ongoing.
While its initial focus was primary schoolchildren and adolescents, today the project targets
the entire population. The initiative is now nationwide and has been adopted by approximately
1000 communities, which offer sports opportunities of all types and for all ages.

Intersectoral action was chosen since the Ministry of Health realized that it could not act on
this issue alone. This triggered a national debate in Parliament on the problem of obesity
and four ministries, in charge of health, sport, family and national education, decided to work
together.

The Ministry of Health and Ministry of Sports took the lead from the outset with the former
maintaining its coordination role throughout. They later engaged the private sector (sports
clubs and school canteen suppliers) in local communities. School catering services also
started offering healthier foods. The media played an important role promoting sport and
balanced diets.

Initially, parliamentary hearings were held and the four ministries established an interministerial
group to plan the project and strategy jointly. They drafted a national plan to fight obesity with
a focus on increasing physical activity and promoting a balanced diet. The interministerial
group is still active and coordinated by a staff member working in the Health Directorate. This
person regularly liaises with all other stakeholders on the project. Funding for this project is
shared between cities and ministries.

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Prevalence of obesity in Luxembourg has remained stable across the population in the
initiative’s 10-year period. Each of the four sectors reaped benefits from involvement in this
project. The general public has increased awareness that balanced nutrition and physical
activity result in better quality of life. A first evaluation is planned for 2016.

Factors that facilitated work were the easy engagement of sectors once the decision was taken
by the Prime Minister to support this project. As a result, it is now easier to contact the Ministry
of Sport and get support when initiating sports activities in communities. The small size of
the country was also a great advantage since it made it easier to reach everyone equitably.
An initial challenge was to engage sports federations or fitness clubs, which were not keen
on promotion of low-priced fitness options, but they now understand that the promotion of
sport for everyone is good for the whole population. The programme has led to an increase
in demand for people who can professional teach sports, which cannot always be met. The
programme is still currently being implemented.

24. Malta: A whole-of-school approach to healthy lifestyles: healthy

eating and physical activity

The major health challenge affecting schoolchildren in Malta is overweight and obesity; almost
47% of 11-year-old children in 2012 were either overweight or obese, with boys showing
increasing trends and girls’ levels of obesity on the downturn. This rapid increase motivated
the health and education sectors to join efforts to implement a national school-wide policy and
strategy to increase physical activity and improve nutrition in schools for all children.

The strategic goals of the initiative were to:

• achieve better physical activity and nutrition for all schoolchildren in Malta; and
• create equal opportunities for all children in all schools to engage in physical activity and
benefit from improved nutrition in school settings.

The national policy and strategy aims to increase opportunities for physical activity and
improve nutrition in schools while allowing the schools to propose locally appropriate actions.
One of the initiatives so far has been increasing physical activity among adolescents in
secondary schools. To achieve this, a health, education and sports working group was set up
and dance sessions offered to students during class breaks. Active changes in foods being
sold in school-based snack shops (tuck shops) have also taken place.

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The policy and strategy, jointly implemented by the health and education sectors, was
triggered by the growing prevalence of obesity among children and the intersectoral action
was built on existing relations with the education sector; this was an opportunity to identify
common goals and work towards them.

The highest levels of government were involved in policy and strategy development; education
and health sectors shared the lead. Many levels of society were involved. Parent associations
were consulted during the development of the policy. The media played an active role in
promotion and information dissemination. The tuck shops changed their purchasing choices.
Cereal companies were informed of the mandatory nutrient levels and sought to promote
healthy cereals.

Mechanisms to facilitate the initiative included the establishment of an intersectoral working

group by the ministers themselves. They also launched events emanating from the policy
such as a “lunch box” campaign using television, radio and social media. School-based
initiatives such as cooking classes on healthy meals for children and parents were offered.
Preparatory work for the initiative was facilitated by a SWOT analysis (strengths, weaknesses,
opportunities, and threats) and policy reviews to assess feasibility.

No additional funding was required for policy and strategy. Each sector used its own budget
and staff time. Positive impact of intersectoral collaboration is apparent in other sectors. The
sports sector, previously promoting “elite” sports, now promotes “health-enhancing physical
activity” at schools. During the summer, children can enrol in non-competitive swimming
classes.

To have successful intersectoral collaboration, the goals of each sector need to be

complementary; conflicting goals impede smooth working. The action needs to be logistically
feasible. Building up personal relations and identifying a champion from each sector is key.
Commitment of people working in the field and at policy level facilitated this process. The
fact that schools were involved in developing the policies supported their ownership of the
initiative.

This initiative had equitable strategic goals; both policy and strategy sought to ensure that all
children would be equally exposed to opportunities for physical activity and good nutrition.
With regard to public participation, parent associations actively provided input to the process.
The media were also involved at various stages, promoting and disseminating information to
the public.

The whole-of-school approach to healthy lifestyles policy was launched in January 2015 and
is currently being implemented.

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25. Monaco: Intersectoral collaboration to test an alert system for

arrival of highly infectious diseases by sea

Work on development of an alert system for dealing with the arrival of highly infectious diseases
in Monaco by sea started in 2013, with a first test carried out using the hypothetical case of
pneumonic plague. The alert system developed aims to ensure a coordinated approach of
highly infectious diseases arrive in Monaco by ship. The system should ensure that affected
people receive appropriate care, health workers are protected and the spread of the infectious
disease is halted.

The core of the alert system is the crisis unit, which relies on a set of intersectoral stakeholders
and procedures to activate if someone with a highly infectious disease arrives in Monaco by
ship. Close cross-border collaboration takes place with France; an international convention
exists since Monaco does not have sufficient infectious diseases specialists. The alert system
includes protocol for health workers, care of affected people and the required infrastructure.

The alert system relies on International Health Regulations, which require every ship entering
a foreign country to submit a Maritime Declaration of Health to the port authority within 24
hours of arrival. If a highly infectious disease is identified on board, the police are notified
and then the Ministry of Health. The crisis unit is convened with relevant sector officials, who
divide up tasks according to expertise.

Intersectoral action for health was a natural choice since emergency operations call for
assistance from health and non-health actors. Monaco needed a system that could be
effectively activated since the Government knew that if an epidemic was to take place, the
country did not have the capacity to address it.

This initiative received ministerial support from many government sectors. The Interior
Ministry (police) receives the Maritime Declaration of Health, the Ministry of Health (ministry
staff) informs hospitals upon receipt of the alert and hospitals provide care to the affected
person. Firefighters (armed forces) provide rescue services, logistics for citizen protection
and organization of transport to the hospital by protected ambulance. The Maritime Affairs
Department, with the Port Authority, facilitates the docking of the ship to evacuate sick people
while limiting ship crossings at that moment. A cruise ship (private sector) was engaged to
increase preparedness through training offered. The media was involved in disseminating
general information about the test locally.

Cross-border collaboration with France is unique to this case story; the French Maritime
Department is involved and infected people are sent to French hospitals for care. The crisis

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unit collaborates with the French medical system and emergency medical services in the
Alpes Maritime Department. The French Navy Prefect and the Maritime Medical Consultation
Centre, comprising doctors who can treat problems that happen at sea, give advice and
arrange care for passengers.

Work was facilitated by abundant sector-specific expertise. During planning there were
meetings with firefighters to learn from their experiences in crisis situations. In infectious
disease emergencies, the crisis unit can ask France for personnel support, relief equipment
and for care of the sick in French hospitals. The crisis unit also proposes public information
messages.

The test of the alert system has led to several adaptations to ways of working, such as
changes in doctors’ behaviours and recognition of the need for increased and continued
training to maintain knowledge. Hospitals need to buy more appropriate materials and health
workers must have better training on materials use, contact with infectious persons and
protection of themselves while caring for the patient. Monaco’s size means proximity fosters
close working relationships. No additional funding was needed as each ministry provided
financing and person time from its own budget. Lack of time and human resources are a
challenge for Monaco; people often carry out multiple functions.

The test of the alert system on the cruise ship confirmed the need to train all sectors to
coordinate and follow established procedure. Firefighters need to have appropriate clothing
and materials. The Ministry of Health needs health information and techniques for dealing
with highly infectious diseases. Regular training of health workers on care of patients and
appropriate materials on ships to protect passengers are essential. The fact that ministers
facilitated this exercise was very positive. Intersectoral collaboration worked smoothly for
Monaco and the experience has been positive for all sectors involved. The test of the alert
system has been concluded and there is a plan to repeat this exercise with a staged chemical
threat situation.

26. Montenegro: Intersectoral action to reduce salt intake in

Montenegro

In 2008, the Ministry of Health Montenegro developed a Strategy for Prevention and Control
of NCDs with a framework for action until 2013. Estimates of circulatory system disease at
approximately 50% (2010–2012) warranted population-wide action to reduce salt intake. A
midterm NCD Action Plan (2014–2015) with intersectoral activities was developed with priority
given to prevention of NCDs and education of food industry staff on reduce salt content in

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foods. The Programme for Reducing Dietary Salt Intake in Montenegro (2014–2025), aims to
reduce salt intake to below 5 g/day per capita, by raising awareness, reducing salt content in
processed foods and through a harmonized national response.

An initiative for reducing salt in bread and baking products was launched by the health
sector and included the baking industry prior to development of the Programme. It is closely
linked to activities from the NCD Strategy and has WHO support from a 2012–2013 Biennial
Collaborative Agreement for implementation of the NCD Framework for Action 2008–2013.
The Programme recommends a reduction in salt intake by 16% during 2014–2020 and by
30% by 2025.

Intersectoral action involving health, agriculture and the private sector was promoted from the
outset, the health sector recognizing that sustainable action was needed with a wider alliance
with other sectors. The Biennial Collaborative Agreement with WHO supported development
of the NCD Action Plan, the Initiative on Salt Reduction and the National Programme for
Reducing Dietary Salt Intake. This policy framework, the NCD morbidity and mortality burden
in the country and comparative transferable experiences on reduction of salt intake were
main triggers for action.

The initiatives had high-level political support and involved diverse stakeholders including
community, civil society and local municipalities. A national council to support the
implementation of the NCD strategy will be established with the Prime Minister acting as
council chair. The main sectors involved in the initiative and programme were health and
agriculture. Other sectors were the chamber of commerce and the private sector, namely
the bakery industry. The media was also instrumental in promoting the programme. They
were invited to events and were provided with information for accurate reporting. The health
sector shared epidemiological data with the agriculture sector to communicate that excessive
salt intake is a health risk factor. An analysis of bakery products revealed high salt content,
and bread became the food vehicle for salt reduction as it is consumed at every meal. An
agreement was reached on the maximum content of salt that would be allowed in bread,
which would be implemented at the local level. A link was made between health and tourism
in the capital, Podgorica, where local authorities and the hospitality sector will offer low salt
options in restaurants in the near future.

A multidisciplinary core group was established to draft the Programme. Continuous dialogue
by means of consultations took place during the Programme’s infancy, such as with the bakery
industry to assure them that business would not suffer. Technical consultations between
health, agriculture and the bakery industry helped to achieve expert consensus, policy-
maker commitment and agreement on maximum salt thresholds. Once legislation passes,
the Ministry of Agriculture will regulate food item labelling to conform to agreed salt levels. An
estimate of 24-hour urinary sodium excretion will be carried out to establish a baseline and
measure progress. The United Nations development framework for Montenegro (2017–2021)

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includes salt intake as an indicator to measure progress in addressing health risk factors.

This experience reaffirms the importance of engaging different sectors from the start and for
regular information sharing. Governance arrangements need a sustainable lifespan covering
the implementation period and should be integrated into existing policies or programmes.
Capacity building for health advocacy is needed so that benefits beyond the health sector can
be reaped. Despite ample evidence supporting salt-reduction programmes, health advocates
do not use it to engage other sectors.

Challenges were lack of budget allocation and knowledge of how to use financial language
and evidence to show positive financial benefits of investing in prevention. International
commitments and global or regional policy frameworks helped to promote intersectoral
collaboration. The existence of subregional technical networks facilitated the exchange of
knowledge, lessons and experiences.

Other sectors such as agriculture now consider health risks of high-salt content when drafting
regulations that deal with labelling. Overall, the intersectoral collaborative process ran
smoothly and transparently with information shared freely among stakeholders. This case
study is just one of several examples of intersectoral action that Montenegro has embarked
upon, showing that the country has embraced accountability across sectors to improve health.

The Programme for Reducing Dietary Salt Intake will be officially adopted in 2016.

27. Norway: National system for the follow-up of public health

policies: a common cross-sectoral reporting system

Norway has a long history of developing and implementing intersectoral action for health at
different levels of governance. A wide array of tools and mechanisms has been developed to
support these efforts. In this case story, the Norwegian national system for follow-up of public
health policies and the common cross-sectoral reporting system are discussed, with a focus
on the cross-sectoral indicators that were developed to support this work. These systems
derive their mandate from government white papers.

White Paper No. 20 (2006–2007; National strategy to reduce social inequalities in health)
highlighted public health policy as a cross-sectoral issue and first launched the cross-sectoral
reporting system. White Paper No. 34 (2012–2013; Public health report: good health, a
common responsibility) reinforced the need for collective action on health and established a
national system for the follow-up of public health policies.

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The main strategic goal was to improve public health and reduce social inequalities in
health. In order to support this work, different sectors have collaborated to create indicators
across sectors to feed back to policy development. For the indicators, data is disaggregated
according to variables such as socioeconomic situation, gender and vulnerable groups. An
interministerial committee with representatives from 12 ministries has worked on developing
these common indicators, and cross-sectoral teams have separately worked on creating
indicators for specific topics such as economic living conditions, social support, safe and
health-promoting environments, health-related behaviour, early life living conditions, work
environment and inclusion, and local public health work.

Collaboration to create the common reporting system and the development of common
indicators has been challenging at times. Getting accurate data is challenging. Not all sectors
routinely collect data, or they have not collected data on socioeconomic variables. The
perception of challenges also varies from one sector to another, as each sector has different
societal goals. In many intersectoral projects and programmes, the health sector has partly
a history of pushing a ready-made prescription of solutions to other sectors, when the right
approach should be negotiated. The determinants approach and reporting system seems to
nurture collaboration. In developing the national system for follow-up of public health policies,
other sectors have been involved from the beginning. Sectors have commonly decided on the
indicators to use in this work. Having data on health-related inequalities, rather than traditional
health data, makes it easier to approach decision-makers in different sectors. Ensuring that
other sectors participate in creating these data will also ensure ownership. Other factors that
have facilitated this work include high-level political commitment and building the capacity of
the health sector in negotiation and in understanding power, process and policy development.

This Norwegian experience demonstrates how intersectoral action on health equality can
be supported through development of common indicators and, more broadly, through joint
reporting and follow-up systems.

28. Romania: Integrated community-based services for health and

well-being

Community-based services have initially been established as pilot activity within field-based
projects funded by different development partners. These started from an initiative for
addressing the health issues of vulnerable population groups in the Roma communities at
local level through establishment of the Roma health mediators. The main objective was to
provide access to health services for the Roma population in the country, and in particular in
several regions with identified lack of services and poor health.

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The activities were in line with the ongoing health reform and the draft National Health Strategy
2014–2020; by far and foremost, activities were based on evidence and best practices
provided by development partners and the Centre for Health Policies and Services during the
2012–2013 implementation of the model project. Furthermore, in order to achieve expected
results by 2020, collaboration with other initiatives in this field was considered in order to build
up a sustainable and coherent framework for further developing integrated community-based
services.

The intersectoral action has grown from a field-based project into a whole-of-government
and whole-of-society initiative addressing health inequalities of some of the most vulnerable
groups at local level; along with this strategic objective, the Ministry of Health has integrated
the community services and continued and formalized the two field professions (community
nurses and Roma health mediators) into the system to work together with the line ministries,
local government, civil society and development partners. Technical expertise and assistance
from WHO, the EU and bilateral cooperation partners has allowed the initiative to move
beyond child survival and to contribute to greater child well-being and increased social and
economic capital in Romania.

This intersectoral action is noted for its prospects of providing better access to health services
for marginalized groups while also improving access to other services (e.g. social, education)
that are prerequisites for better health and well-being. It has thus contributed to reducing
health inequalities through joint action and through addressing multiple social determinants
of health, with the aim of providing equal opportunity for prosperity for everyone.

29. Republic of Moldova: National Reproductive Health Strategy

2005–2015

Reproductive health has been a long-standing priority in the Republic of Moldova. With
history of long-term collaboration with international partners in provision of free contraceptives
and reproductive health services, in 2005 the Ministry of Health moved forward into the
process of providing sustainable reproductive health services and initiated the development,
endorsement and implementation of the National Reproductive Health Strategy 2005–2015.

The initiative has built upon the previous efforts of the Ministry of Health, supported by other
line ministries, intergovernment agencies and development partners to address the issues of
reproductive health, in particular mother and child health, in order to efficiently reduce the infant
and maternal mortality rates in the country. Upon successful development, endorsement and
implementation of the Strategy, the Ministry of Health, together with its development partners

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and with technical support from WHO, has initiated a process of evaluation of the Strategy
with a view to development of a new Reproductive Health Strategy for the next five-year
period. The evaluation revealed important issues to be addressed in all of 11 priority areas
assessed within the strategy, and currently the country is in the process of development and
endorsement of the new strategy, based on the lessons learnt. The key supporting factors
are the political will and the set priorities of the Moldovan Government, together with the
strong leadership role of the Ministry of Health; among the key challenges are the funding
and monitoring, for which the country has already set new goals for the upcoming strategic
document. The process of development of the new National Reproductive Health Strategy
involves multiple sectors and stakeholders because the evaluation of the 2005–2015
programme emphasized that the key to its successes was coordinated joint actions across
government and society.

30. San Marino: EXPO 2015: an opportunity to highlight the

importance of nutrition and sustainable agriculture in school
settings

According to data from the WHO COSI study (2), 31% of primary schoolchildren in the
Republic of San Marino are overweight or obese. This case story reports on the incorporation
of nutrition and agricultural components in an existing nutrition in schools project. It shows
how intersectoral action and an international event (EXPO 2015) can promote balanced diets
and food-quality standards that prevent overweight and obesity among children.

The strategic goal was to ensure that all children in San Marino had access to sustainably
grown nutritious foods in school and educational opportunities to learn about these foods.
Equity, gender and human rights were implicitly considered; all children in San Marino are
offered these foods at school. EXPO 2015 provided an opportunity strengthen the nutrition
in schools project already in place while providing education to children on the importance of
food quality.

Two congressional resolutions backed this process. A 2013 congressional resolution was
passed calling for the establishment of a multidisciplinary and intersectoral working group for
planning and coordination of the health promotion and education interventions in schools.
Another congressional resolution on EXPO focused on promotion of balanced diets and food-
quality standards was also passed.

Sectors took turns in leading the initiative. The Ministry of Health, with the support and
coordination of the Health Authority, provided guidelines on health education in school settings

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and guidance to dieticians and paediatricians on menu development and special diets. The
Ministry of Education ensured a link was made between school science lessons and off-
campus workshops. The Ministry for Tourism, responsible for EXPO, highlighted agricultural
production in San Marino to the outside world. The agriculture sector (Terra di San Marino
agricultural consortium) organized workshops for schoolchildren on their different products.
They agreed to follow a number of integrated agriculture standards that would help to ensure
sustainable production of the six main food products. The media highlighted and promoted
best practices and broadcast programmes highlighted food quality and healthy diets.

While the consultative committee for EXPO had a time-specific mandate, the education for
health working group will ensure sustainability. EXPO 2015 had its specific funding and the
initiative built on activities already in place.

While it is early to see the health effects or decreases in obesity, indirect evaluations
carried out every two years, such as “Occhio alla salute”, will provide indications of change
in overweight and obesity. Intersectoral work was successful with an indicator of interest
being high attendance at nutrition workshops organized by the agricultural consortium (1500
children). Other elements to evaluated are the effects of direct training of cooks by dieticians
from the Institute of Social Security, knowledge passed on to children by teachers in science
lessons and the results of a dietary assessment of children in third grade.

If there is strong government support, a mechanism such as the education for health working
group can be activated. Using a major event such as EXPO 2015 provides an opportunity for
the country to bring together all its skills to work on a common project. An understanding by
all stakeholders of integrated work helped to streamline work and led to better coordination.
Finding a common language between schools and the health sector as well as identifying
goals that were of mutual benefit were also challenges that were overcome.

Despite the fact that EXPO 2015 is finished, the education for health working group remains
intact and the agricultural consortium continues to supply school cafeterias with sustainability
grown healthy foods.

31. Serbia: Implementation of the Protocol on Water and Health

The Republic of Serbia ratified the Protocol on Water and Health and in April 2013. Article 1
of the Protocol states that its objective is “to promote at all appropriate levels, nationally as
well as in transboundary and international contexts, the protection of human health and well-
being, both individual and collective, within a framework of sustainable development, through

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improving water management, including the protection of water ecosystems, and through
preventing, controlling and reducing water-related disease”.

According to the Law on Ratification of the Protocol on Water and Health, ministries responsible
for health, water management and environmental protection ensure Protocol implementation.
The “Agreement on the Establishment of the National Working Group in Order to Undertake Joint
Measures and Activities Important for the Implementation of the Protocol on Water and Health
to the Convention on the Protection and Use of Transboundary Watercourses and International
Lakes” was signed between the Ministry of Health, the Ministry of Energy, Development and
Environmental Protection and the Ministry of Agriculture, Forestry and Water Management. The
ministerial agreement resulted with the establishment of the National Working Group.

In order to systematically review the legal framework (national and international) and the
water, sanitation and health situation in Serbia, a baseline analysis was performed as the first
technical step and to support a tool to facilitate drafting targets and target dates. This analysis
was essential for the setting of priority issues and actions under the Protocol and resulted in
targets and target dates being set.

Beyond the whole-of-government approach, other stakeholders involved have broadened the
scope to the whole of society; NGOs and the media were actively involved, and activities for
collaboration with the private sector were initiated.

To date, no funding mechanism has been established, and the work of the National Working
Group is on voluntary basis. However, to ensure sustainability, financial support is needed
for further implementation of the Protocol and increased capacity is required for developing a
tool for performing cost–benefit analysis for Protocol targets.

32. Slovenia: Development of the Active and Healthy Ageing

Strategy

Slovenia has adopted and with some success implemented the Active and Healthy Ageing
Strategy 2006–2010. Because of the enormous challenges from demographic trends in
the country, two attempts to prepare the new Strategy in the period 2010–2013 were not
successful. It was very clear from the two unsuccessful attempts that an intersectoral approach
with engagement and participation of stakeholders, even mobilization of society, would be
necessary for successful preparation of the Strategy. The Strategy SI project was finally
launched and implemented in March 2014 to February 2016, resulting in a governmental
decision in January 2016 to prepare a comprehensive national strategy to respond to the

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longevity challenges in Slovenia society. The Ministry of Health and the Ministry of Labour,
Family and Social Affairs were highly interested in participating in the preparation of the
proposal of measures for the Active and Healthy Ageing Strategy for Slovenia.

This initiative was triggered by several parallel processes. The European Commission adopted
the Social Investment Package in the beginning of 2013 and the Directorate-General for
Employment, Social Affairs and Inclusion was interested testing the implementation potential of
the Package in one of the EU Member States; because the country-specific recommendations
for Slovenia in the EU Semester 2016 included structural reforms, in particular on pensions,
health, long-term care, the Ministry of Health proposed that its Active and Healthy Ageing
Strategy should become the testing area. The Ministry of Health approached the Ministry
of Labour, Family and Social Affairs to initiate the intersectoral process. The latter ministry
involved the Ministry of Education, Science and Sport because of its role in lifelong learning
initiatives.

The evaluation tools (questionnaires, interviews, meetings and conference participation) have
showed that an important momentum of engagement was created. This involved not only
different stakeholders but also policy-makers from government level (the three ministries).
The commitment of the Slovene Government to the outcomes is noticeably high, as evidenced
by the participation of ministers and state secretaries at events and conferences in addition to
their involvement in strategic decisions. Most importantly, on 21 January 2016, the Slovene
Government adopted the decision on preparation of holistic policy response to demographic
change in Slovenia. The project has increased the awareness and understanding of healthy
and active ageing principles and addressed the challenges posed by financial constraints,
existing systems and regulatory frameworks.

The main challenge at the initiation of the process was the relatively low multisectoral competence
of the project partners. For first six months, definitions and understanding of common issues
were developed. Modes of action also varied within the social, economic and health partners’
organizations and some time was needed for adaptation to the common working procedures.
In the implementation stage, high sensitivity for simultaneous political processes was needed
and fine-tuning of the processes was an absolute for the project. The EU country-specific
recommendations for Slovenia in the area of prolonged employment and postponed retirement
and in the area of long-term care were the main facilitating factors for the SI process. High
political will and determination to create results at the Ministry of Health and the Ministry of
Labour, Family and Social Affairs were important driving forces. Involvement of all relevant
stakeholders, participatory research, targeted engagement and mobilization of different
groups of stakeholders, understanding of different positions and needs of stakeholders, testing
proposed political measures in local environments and consensus-building processes, all with
focus on health equity, were important success factors in the project.

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33. Spain: National Strategy on Patient Safety

A national Strategy on Patient Safety was adopted in Spain 2005 and formed a key element
in the Quality Plan for the health service. The Strategy was updated and renewed for 2015–
2020. It is based on international recommendations from the WHO, EU and national experts.
The Strategy is implemented by a Network for Patient Safety led by the national Ministry of
Health and made up of the 17 regions and two autonomous regions that have responsibility
for the delivery of health care.

At national level, there are coordinators for each working group of experts and ministry
officials. At regional level, the framework includes staff from regional bodies and health care
specialists. The Strategy on Patient Safety is coordinated locally in hospitals or within primary
care, with data being aggregated regionally and nationally. Each of these working groups has
regular teleconferences and annual meetings. The full network is convened once or twice a
year to agree the objectives and actions for the year and review progress.

At the request of the regions, the national Strategy on Patient Safety was updated. Stakeholder
involvement was ensured by contributions from a group of multidisciplinary experts, all
regional authorities and 70 scientific societies and patient organizations.

The new focus in the updated Strategy is on making surgery safer, bringing in the professional
associations related to surgery and collaborating with the National Nuclear Council to prevent
adverse events linked to radiation.

The Ministry of Health leads the Strategy on Patient Safety. There have been some attempts
to involve the Ministry of Education but no formal agreement has been signed. Some
relationships have been created with universities through members of scientific societies who
also have a teaching function.

Facilitating factors include strong leadership and political commitment, investments in

education tools and implementation projects, evaluation of the activities and feedback. The
main obstacles to achieving better patient safety are an overall lack of safety culture, gaps in
professional training and communication skills, and resistance to change within the system.

Patient organizations helped to develop the Strategy and are involved in all working groups.
Since 2006, there has been special training for patients to raise their awareness about patient
safety issues and empower them to train others.

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The Strategy was initially funded by the Ministry of Health and financial support was limited to
a communication campaign on hand hygiene; there have been no funds allocated since 2011.
However, an EU funded project on patient safety from 2012 to 2016 has allowed regional
authorities to access ongoing training and good practices.

Specific projects on reducing infections (Bacteraemia Zero and Pneumonia Zero) have
delivered good results in terms of lives saved and reductions in hospitalization costs.

Leadership is needed at all levels; failure at one level is very visible in some projects. For
example, the Bacteraemia Zero project saw smaller reductions in infection in regions without
strong leadership.

The decentralized nature of health care in Spain means that it is not easy to achieve coordinated
movement in the same direction. There is agreement on the importance of patient safety and
the regions share the task of developing the strategic objectives.

34. Sweden: Promoting social sustainability through intersectoral

action at the local and regional level

In Sweden, social sustainability has been promoted through intersectoral action at the local
and regional level. In 2011, the Swedish Association of Local Authorities and Regions, at the
request of some municipalities and regions, initiated an intersectoral project, Joint Action for
Social Sustainability, to reduce inequalities in health in 2011–2013. The work was initiated as
a response to health inequality problems, which were evident at both local and regional levels.
The project was started as a joint local and regional effort, acknowledging the fact that facing
these problems would require the efforts of multiple sectors. As a result of this initiative, the
Swedish Association, in collaboration with the Public Health Agency of Sweden, established
an intersectoral Social Sustainability Forum (2014); this includes 16 representatives from the
local and regional authorities, state authorities, the private sector and the civil society.

The Forum aims to promote welfare in a socially sustainable way by providing for the basic
needs of all people, by guaranteeing human rights in practice and by contributing to the
inclusion of all people. More specifically, it aims to strengthen knowledge about how to
implement social sustainability issues in regular governance and management systems, and
to pursue successful strategic cooperation within and between the public sector and NGOs,
the business sector and the research community.

The Joint Action for Social Sustainability and the Social Sustainability Forum are good
examples of local and regional level intersectoral action, and there are many key lessons to

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be learnt from this experience that may benefit local, municipal and national decision-makers
and other actors in other countries. First, use of term social sustainability instead of public
health has been innovative. Terms and goals such as “reducing the health gap” are not always
understood or appealing to other sectors, and “social sustainability” language was seen to
work better with other sectors in Sweden than typical public health language. Another lesson
is that clear short-term and long-term goals should be set. At the local level, the focus of
action should be on what can be changed – in other words, issues that are the responsibility
of the local governments. The fact that some sectors have national policy goals whereas
others may set their goals at the local level can complicate intersectoral working. Actions
should also be prioritized and, importantly, economic impact needs to be demonstrated to
policy-makers. Costs of the actual intersectoral actions should be carefully planned, and this
should be taken into consideration in prioritization of actions. Sustainability and ownership of
intersectoral action was deemed good in this case, because it was initiated from the bottom to
the top: some municipalities and regions asked the Swedish Association of Local Authorities
and Regions to take a national lead in coordinating support for local intersectoral action
for health. The local stakeholders benefit from the support they receive from the Swedish
Association and the Public Health Agency of Sweden.

35. Switzerland: Swiss Health Foreign Policy

The process of globalization in general and of the public health sector has generated a great
demand for coordination between health, foreign and development policies. Thematic areas
such as transport, environment, energy, security and global health are increasingly important
topics in international relations. They play a substantial role in the sustainable development
of societies and can, therefore, no longer be addressed in isolation – nor be restricted to a
state’s territory. In order to ensure Switzerland’s capability to be a convincing partner with a
coherent position and to represent its interests in the best way possible, the Swiss Health
Foreign Policy was approved in 2012 to serve as an instrument for this coordination. This has
equipped Switzerland well to formulate and implement a coordinated and coherent health
policy approach at both national and international levels.

Switzerland was the first country to adopt an interministerial agreement on health foreign
objectives, which it did in 2006. Since the agreement was signed, it has been regarded as a
model at the international level. Swiss Health Foreign Policy is the revised version of the 2006
Agreement of the Health Foreign Policy Objectives. The consultation process involved relevant
federal authorities, interested parties from civil society, the private sector, research, Swiss health
system actors, and the Swiss Conference of the Cantonal Ministers of Public Health.

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Swiss Health Foreign Policy covers all international concerns related to health with
neighbouring countries, with European policy, on the subject of global public goods and
development policy. It relates to 20 objectives in the area of governance, interactions with
other policy areas and specific health issues that are of interest to the Swiss population,
either as part of a global responsibility for health or of general interest. The national objectives
that influence international cooperation are defined in the Health 2020 Strategy, which was
approved by the Swiss Government in January 2013.

A focused and intersectoral approach was used to ensure that Swiss values such as human
rights, the rule of law and democracy are guaranteed and that the interest of a wide variety of
Swiss actors can be taken into account.

Coherence within the Federal Administration is a key success factor for Swiss Health Foreign
Policy. The mutual gains were identified as new forms of cooperation, improved integration
of wide variety of activities in the health field, and taking a more systematic approach to the
development of synergies in all sectors involved.

Interdepartmental structures include the Interdepartmental Conference on Health Foreign

Policy, which defines current priorities and joint projects. It meets annually and is jointly chaired
by the Director of the Federal Office of Public Health, the Director of the Swiss Agency for
Development and Cooperation and the State Secretary of the Federal Department of Foreign
Affairs. The Interdepartmental Conference is supported by interdepartmental working groups,
which hold regular meetings at least twice a year. An executive- level support group meets at
least twice a year to promote policy coherence and to reach consensus if necessary.

Trust and partnership building needs time. While the diversity of the issues involved keeps
increasing and their complexity grows, the resources to implement the Health Foreign Policy
remain limited. Therefore, the constant challenge is to focus on the concerns and the partners
who are expected to generate the greatest added value for public and global health interests.

36. The former Yugoslav Republic of Macedonia: Government

Committee on Environment and Health

The former Yugoslav Republic of Macedonia has made an effort to improve the health and
well-being of the population to reduce health inequalities, to advance public health and to
ensure a health system where the people will have a central position. WHO’s Health 2020
framework has been used as guidance and a source of best practices in developing the first
overarching national health policy since the independence of the country.

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The Environment and Health Action Plan has been developed as part of the implementing
strategy for the National Health Plan. This development has directly evolved from the active
role of the country in the WHO European Region process for health and environment. As a
result, national environment and health processes have been strong, with a central role for
the expert community in moving the Environment and Health Action Plan forward, lobbying
for changes, bridging sectors and informing the public of the evidence and related action to
remedy the situation.

Using this opportunity to keep health in the focus of the Government, the Minister of Health
requested technical assistance from the WHO Country Office to engage in making a case for
an overarching environment and health action plan (and public health) and policy development.
WHO 2014 and 2015 biennium work was focused on filling the evidence gaps, where the
WHO Regional Office for Europe and WHO European Centre for Environment and Health in
Bonn have been deeply involved. The Ministry of Finance was brought into the initiative and
became interested because the actions detected during the process would require significant
funds to be employed (e.g. for action in the areas of transportation, energy or industry).

The WHO missions supported intersectoral work on evidence gathering while a policy
dialogue was opened by the Ministry of Health, fully supported by WHO. This has broken
the “silo thinking” of all the sectors involved, particularly health, environment and transport.
Central and local levels were included.

Drafting of the Action Plan on Environment and Health was completed in August 2015 and
the draft was posted for public debate alongside other public debate areas on the Ministry
of Health site designated for the overarching Health Policy 2020 (http://zdravstvo.gov.mk/
health_2020/).

The Action Plan on Environment and Health presents one of the main pillars of, and venues
to implement, the Health Policy 2020 in the former Yugoslav Republic of Macedonia and is
expected to be endorsed by the Government in the first half of 2016.

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Conclusions
The analysis of the 36 collected case stories emphasizes the notion that fostering effective and
sustainable multisectoral and intersectoral action is key to ensuring improved health and well-
being for all throughout the European Region. Furthermore, multisectoral and intersectoral
action and collaboration are necessary for the new transformative model of governance
needed to achieve the 2030 Agenda. Multisectoral and intersectoral action needs not just to
occur across sectors but also to be coherent across levels of governance – from international,
to national to local. WHO has mechanisms to achieve this coherence, such as the WHO
European Healthy Cities Network and the Regions for Health Network, which work at the
local level for the improvement of health and well-being for all.

Promoting transformative change in line with the 2030 Agenda

The 2030 Agenda calls for a transformative response to our global challenges, in order to meet
the 17 SDGs. The analysis of these case stories shows that multisectoral and intersectoral
action for health and well-being can do more than simply address immediate health and well-
being problems; it can improve health and well-being outcomes for all.

By addressing the determinants of health and well-being, multisectoral and intersectoral

action can encourage more fundamental, health-promoting changes in sectors beyond the
health sector. The ability to inspire this kind of transformative change is particularly critical
for the achievement of the 2030 Agenda and the strategic objectives of Health 2020, which
requires transformative governance. The involvement of diverse actors across all levels of,
government, and beyond, is necessary to achieve global, regional and national goals and
targets and to effectively address today’s complex global challenges. The transformative
approach to improved governance is facilitated through whole-systems approaches (whole
of government, whole of society, whole of city, whole of school) that engage all levels of
governance, from the international through the national and the regional to the local.

Transformative change means going beyond business as usual. In 27 of the 36 case stories,
there was a reported change in another sector in addition to the health sector, with only nine
being restricted to the health sector. Most often, this kind of transformative change manifested
by ensuring that health and well-being concerns were given a higher priority within other
sectors, and by changing institutional structures and practises both within and beyond the
health sector.

Long-term vision and political commitment, from the highest levels down, are needed to
implement multisectoral and intersectoral actions for health. Ideally, this commitment should
be operationalized in long- and short-term goals, measurable indicators and targets with a
monitoring and accountability framework. Special attention should be paid to horizontal and

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vertical coordination within and between sectors. However, it was also noted that bureaucratic
procedures were often a barrier rather than a facilitating factor. Engaged policy-makers and
technical experts should be given reasonable levels of autonomy and independence to take
decisions without the impediment of heavy bureaucracy when multisectoral and intersectoral
mechanisms are implemented.

Furthermore, it is critical that the health sector develops its capacity to bring other sectors
into a given process, which requires strong partnership and collaboration. Good collaboration
is based on trust, which takes time to build, and concrete results can only be expected after
this initial time is invested. Creating ownership across sectors is crucial; this is best fostered
by involving all key actors from the start, communicating clearly using accessible language,
providing reliable information and ensuring that the factors to ensure the sustainability and
continuity of the collaboration are in place.

Identifying win–win situations and co-benefits for all involved is vital in order to strengthen the
commitment of stakeholders across different sectors. It is also important to identify partners
with influence on the policy question at hand (e.g. certain politicians, NGOs, professional
bodies, media representatives and other groups with shared interests). Equally, it is beneficial
to identify the opposition and their arguments (e.g. private actors with vested interests or
strong interest groups with conflicting ideas or values). This is particularly important given
the essential role of intersectoral and multisectoral approaches to addressing key public
health priority areas. Where there are conflicts of interest or strong commercial determinants
of health, a strengthened governance approach is critical for effective action. This includes
strengthened governance for health and well-being not only within health governance but
also across all governance architecture up to the highest levels of both government and
public institutions.

Actions should be prioritized, and their social and economic impact should be demonstrated
through evidence whenever possible. The focus of the multisectoral and intersectoral action
undertaken should be both realistic and achievable, making continuity and sustainability
more likely. Various tools (e.g. health impact assessments) and other methods for public
consultation and community participation should also be used throughout the process in order
to increase its legitimacy and efficiency. There is a clear role for WHO in supporting methods
for implementation through the development of tools to strengthen existing implementation,
and innovation through sharing good practice on the effectiveness of new instruments and
mechanisms.

A legislative base can give a strong mandate for multisectoral and intersectoral work and can
facilitate cross-sectoral collaboration. Mandates may include more traditional constitutions,
laws and decrees but may also include institutional guidelines, strategies, and action plans at
the national or local level that can steer actors toward multisectoral and intersectoral action.
To ensure continuity, it is important that multisectoral and intersectoral mechanisms exist

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beyond election periods and particular electoral mandates, as political changes can quickly
abolish initiatives and mechanisms established by a previous government. Therefore, varying
types of permanent multisectoral and intersectoral structure are needed to guarantee stability
and sustainability. This suggests the importance of an integrated approach to governance for
health and well-being, through both existing governance architecture, and central policies and
processes such as national development plans and national strategic economic documents.

These case stories have also contributed to an improved understanding of the role of the
WHO Regional Office for Europe in promoting new approaches and models for governance
to support multisectoral and intersectoral for health and well-being throughout its 53 Member
States. The 2030 Agenda demands a framework to better understand and support governance
for health and well-being, as well as tools to apply it across different contexts.

This mapping exercise aimed to collate and share examples of best practice of multisectoral
and intersectoral action to improve health and well-being for all throughout the WHO European
Region. The case stories collected cover a wide range of topics and policy areas and have
been implemented in varying contexts. Both multisectoral and intersectoral actions are
necessary to achieve the 2030 Agenda, and the case stories collected here aim to contribute
to the achievement of this transformative, global and common agenda.

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12. Regional Committee for Europe resolution EUR/RC65/16 on promoting intersectoral action for
health and well-being in the WHO European Region: health is a political choice. Copenhagen:
WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/assets/pdf_

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file/0004/284260/65wd16e_PromotingIntersectoralAction_150619.pdf?ua=1, accessed 7 March

2018).

13. Sustainable development goals. Geneva: World Health Organization; 2016 (http://www.who.int/
topics/sustainable-development-goals/en/, accessed 8 March 2018).

14. Health in 2015: from MDGs to SDGs. Geneva: World Health Organization; 2015 (http://www.who.
int/gho/publications/mdgs-sdgs/en/, accessed 8 March 2018).

15. Health in all policies: framework for Member State action. Geneva: World Health Organization;
2013 (http://www.who.int/healthpromotion/conferences/8gchp/130509_hiap_framework_for_
country_action_draft.pdf, accessed 7 March 2018).

16. Helsinki statement on health in all policies. In: Eighth Global Conference on Health Promotion,
Helsinki, 10–14 June 2013. Geneva: World Health Organization; 2013 (http://www.who.int/
healthpromotion/conferences/8gchp/statement_2013/en/index1.html, accessed 7 March 2018).

17. Health in all policies training manual. Geneva: World Health Organization; 2015 (http://who.int/
social_determinants/publications/health-policies-manual/en/, accessed 7 March 2018).

18. Beyond bias: exploring the cultural contexts of health and well-being measurement. In: First
Meeting of the Expert Group on Cultural Contexts of Health and Wellbeing, Copenhagen, 15–16
January. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/
assets/pdf_file/0008/284903/Cultural-contexts-health.pdf, accessed 8 March 2018).

19. The European health report 2015. Targets and beyond: reaching new frontiers in evidence.
Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/en/data-and-
evidence/european-health-report/european-health-report-2015/ehr2015, accessed 8 March 2018).

20. Roadmap for action, 2014–2019. Integrating equity, gender, human rights and social determinants
into the work of WHO. Geneva: World Health Organization; 2015 (http://www.who.int/gender-
equity-rights/knowledge/roadmap/en/, accessed 8 March 2018).

21. WHO handbook for guideline development second edition. Geneva: World Health Organization;
2014 (http://apps.who.int/medicinedocs/documents/s22083en/s22083en.pdf, accessed 8 March
2018).

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Annex 1. Template for case stories on multisectoral

and intersectoral action for health and well-being
(interview guide)
The questions in this template are partially adapted from a case study template developed
by the WHO Centre for Health Development (in Kobe) and the WHO Regional Office for the
Americas (AMRO/PAHO) (1) and from case study guidelines developed by the Public Health
Agency of Canada in collaboration with WHO (2). In addition, the work builds on the WHO
Regional Office for Europe’s internal working paper Mapping exercise to support multisectoral
and intersectoral action: results of the in-house consultation with programme managers, unit
leaders and technical officers at the WHO Regional Office for Europe. This mapping exercise
uses an umbrella term multisectoral and intersectoral action for health and well-being to
refer to a number of approaches (e.g. whole-of-government or whole-of-society approach,
HiAP, healthy public policy and social determinants of health approach) that highlight the
importance of working collaboratively across sectors to promote health.

SECTION 1: Background Information

Name of the case story

Member State

Contact person (consultant/rapporteur) Name:

Title:
Telephone (incl. Member State code):
Email:
Address:

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Contact person (in-Member State) Name:

Title:
Telephone (incl. Member State code):
Email:
Address:

Brief description of the case story and its

focus including the time span
(3–5 sentences: what was the issue/
challenge)

Describe the key strategic goals (*GER)2

At what level is the case implemented? □ International

□ National
□ Regional
□ Local
□ Other, please specify:
How the nature of the case can be best
described?
(E.g. a project, strategy, action plan,
permanent/temporary structure, law, tool,
other)
What is the level of intersectoral action in □ Information sharing: A one-way
the case example? relationship where information from
Please mark all that apply one sector is shared with other sectors.
(Descriptions adapted from WHO Kobe, This may be the first step towards an
2013 (1) and Shankardass et. al. 2011 (3)) intersectoral process.
1

2 Please consider this question also from a GER (gender, equity, and human rights) perspective.

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□ Cooperation: Interaction between

sectors to achieve greater efficiency in
their actions. This involves optimizing
resources while establishing formalities in
the work relationships. It results in a loss
of autonomy for each sector and may be
one of the first stages of an intersectoral
process.
□ Coordination: Adjusting the policies
and programmes of each sector. This leads
to increased horizontal networking among
sectors. Shared financing sources may be
used. This is an intersectoral relationship
that leads to greater dependence between
sectors and loss of autonomy.
□ Integration: A political process where a
new policy or a programme (representing
multiple sectors) is defined. This may entail
systematic integration of objectives and
administrative processes and the sharing of
resources, responsibilities and actions.
□ Other, please describe:

SECTION 2: Setting, Background, and Implementation

What or who stimulated/triggered the

initiative (a brief description of the
process)?

Why intersectoral action was chosen as a

better way to achieve the goal as compared
to involvement of one-sector alone?

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Describe the role of political will and how

higher levels of government have been
involved

Describe the roles of the main sectors

involved. Did a cross-sector team exist?
List all sectors involved
(*GER)

Describe the win–win situations/co-

benefits/mutual gains that can be identified
to different sectors

Describe the role of the health sector and

that of the leader/initiator/coordinator of the
process

What other mechanisms were used to

facilitate the work between the sectors?
(A list of mechanism here?)

Describe the financial mechanisms of the

case; does it possess its own budget or is
joint funding available?

Have any non-governmental actors been

involved (e.g. NGOs, the private sector)?
Describe their role and specific contribution

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Describe the role of public participation;

were there any participatory mechanisms
utilized?
(*GER)

Describe the role of media in initiation and

implementation of the case (if applicable)

Were any tools utilized to facilitate the work

(e.g. health impact assessments, policy
reviews, parliamentary hearings etc.)
(*GER)

Other considerations

SECTION 3: Policy Considerations

Is the work with other sectors supported □ No

by a mandate (e.g. law, decree, act,
government policy)?
□ Yes, please describe
Description:

Was there an inter-ministerial or inter- □ No

departmental committee?
□ Yes, please describe
Description (if possible, please include
an organigramme depicting the different
actors/sectors):

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Has the case led to (policy) changes in □ No

other sectors?
□ Yes, please describe
Description:

Has the case involved or led to □ No

collaboration between the public and
private sectors?
□ Yes, please describe
Description:
(Considerations: accountability,
transparency, conflict of interests, risk
assessment, good governance?)
Other considerations

SECTION 4: Impact and Lessons Learned

What were the key lessons learned?

Was each of these a generalizable lesson
or context-specific?

Describe to what extent have the objectives

been met in relation to
1) work with other sectors
2) other expected outcomes
(e.g. improvements in health and/or
its determinants)
How and by whom were the objectives
assessed/monitored/evaluated?
(*GER)
Are any measurable outcomes or indicators
set to measure the impact?

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Describe the perception/acceptance of the

action by different actors
(E.g. politicians, civil servants, the media,
and the general public)

Describe the key challenges/barriers

encountered in the initiation and
implementation of the case
(E.g. political, institutional, bureaucratic,
skill-related, knowledge, other?)
Describe the main facilitating factors in
the initiation and implementation of the
case
(E.g. political, institutional, bureaucratic,
skill-related, knowledge, other?)
Based on these experiences, what kinds of
capacities/tools/resources might be needed
to support a successful implementation
of intersectoral action for health and well-
being in the future?
(*GER)
Is it likely that the practice can be applied
to other Member States/regions?

SECTION 5: Evaluation and Dissemination of the Results

Has any literature been published about □ No

this case (e.g. formal evaluations by
research institutes etc.)?
□ Yes, please specify
Description:

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Has the media been included in evaluation □ No

or dissemination of the results of the case?
□ Yes, please describe
Description:

Please attach any material or evidence of

the experience

Does this case example have a website

and can it be found online on social
networks?

Any additional comments (e.g. how was

the case perceived/presented; what is the
perceived legacy?)

SECTION 6: Overall Summary

Title:

Abstract (300–500 words):

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References
1. Annex II. Guidelines for case studies on intersectoral action for health and wellbeing (ISA). In:
Synthesis report of intersectoral action for health and wellbeing case studies. Internal report. Kobe:
World Health Organization Centre for Health Development; 2014.

2. Intersectoral action for health and wellbeing: analysis of experiences. Draft case study guidelines.
Ottawa: World Health Organization and Public Health Agency of Canada; 2007 (http://www.who.
int/social_determinants/media/iah_tor_case_studies.pdf, accessed 7 March 2018).

3. Shankardass K, Solar O, Murphy K, Freiler A, Bobbili S, Bayoumi A et al. Health in all policies:
a snapshot for Ontario, results of a realist-informed scoping review of the literature. Ontario: St
Michael’s; 2011.

83
The WHO Regional
Office for Europe

The World Health Organization (WHO) is a

specialized agency of the United Nations created in
1948 with the primary responsibility for international
health matters and public health. The WHO Regional
Office for Europe is one of six regional offices
throughout the world, each with its own programme
geared to the particular health conditions of the
countries it serves.

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Original: English