INTERSECTORAL COORDINATION IN INDIA FOR

HEALTH CARE ADVANCEMENT

1. INTRODUCTION

Health is the precious possession of all human beings as it is an asset for the individual and
community as well. In 1946, the world health organization presented definition of health in
the preamble of its constitution. It defines Health is a state of complete physical, mental and
social wellbeing and not merely the absence of disease or infirmity. Health and quality of life
of individuals and populations are determined by a complex net of interrelated factors. These
factors cover the broader determinants of health including social, environmental, and
economic determinants. Such complexity means that measures to promote and protect health
and well-being cannot be confined to the health sector alone. Designing and implementing
public policies that improve quality of life require the active involvement and engagement of
other sectors of society in all steps of the process. In most countries of the world new health
challenges are constantly arising. Combined with the added complexity of rapidly growing
urban settings, the need for the engagement of other sectors is ever-growing. This generates a
need for relevant tools and practical examples of how the health sector can successfully
engage with other sectors.1, 2

2. DEFINITION INTERSECTORAL COORDINATION

Intersectoral coordination has been described by the World Health Organization in 1997 as:

"A recognized relationship between part or parts of the health sector with part
or parts of another sector which has been formed to take action on an issue to
achieve health outcomes, (or intermediate health outcomes) in a way that is
more effective, efficient or sustainable than could be achieved by the health
sector acting alone."

Intersectoral coordination demands coordinated efforts of all sectors such as

Agriculture, Irrigation, Animal Husbandry, Education, food, Social and Women's
Welfare, Housing and Public Works, Communication, Rural Development,
Cooperatives, Industries, Panchayats and Voluntary Organizations, etc.3

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3. INTERSECTORAL COORDINATION FOR HEALTH: A
BROAD SPECTRUM OF APPROACHES4

The concept of intersectoral action was introduced at the International Conference on Primary
health Care in Alma-Ata, Kazakhstan in 1978. In the 1980s, conferences related to
intersectoral Action (IA) and the Ottawa Charter further underscored the need to work
between sectors to realise health gains. WHO notes A formal commitment to Intersectoral
Action became part of many countries official health policy frameworks in the 1980s.
However, the track record of actual results from national implementation of IA was feeble. IA
to address social and environmental health determinants generally proved, in practice, to be
the weakest component of the strategies associated with Health for all (WHO, 2005). In
1990s, with the growth of knowledge on determinants of health, efforts to work across sectors
also expanded. In 1997, the WHO hosted a special conference on IA. In 2000, the Bangkok
Charter for Health Promotion confirmed the need to work across sectoral boundaries.

In 2006, the European Union introduced Health in All Policies, a broad-reaching directive
with implications for intersectoral policy development, implementation and evaluation
(Evans & Vega 2006,). A Health in all Policies conference was held by the European Union
in September 2006, for which the Finnish Ministry of Social Affairs and Health produced a
book entitled Health in all Policies Prospects and Potentials. The book describes sectoral
experiences in health in all policies on, for example, health at the workplace. One part is also
dedicated to opportunities and challenges of health governance, another on health impact
assessment. The conclusions recognize that even if in many policies, the combined strategy of
other policies with health will be a mutual gain, in some cases the values and objectives of
the various policy intentions can be incompatible. In such cases, it is suggested that aims and
objectives need to be negotiated and compromises sought (Sthl, T. et al. 2006).

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4. IMPORTANCE OF INTERSECTORAL
COORDINATION

4.1) Intersectoral coordination& primary health care (PHC)

Intersectoral coordination is one of the principles of primary health care. The Alma-Ata
international conference in 1978 defined primary healthcare as; primary health care is an
essential health care made universally accessible to individual and acceptable to them,
through their full participation and at a cost the community and country can afford. There is
an increasing realization of the fact that the component of primary health care cannot be
provide by the health sector alone. The Declaration of Alma-Ata states that primary health
care involves in addition to the health sector, all related sector and aspect of national and
community development, in particular agriculture, animal husbandry, food, industry,
education, housing, public works, communication, and other sector. To achieve such
cooperation, countries may have to review their administrative system, reallocate their
resource and introduce suitable legislation to ensure that coordination can take place.5

4.2) Intersectoral coordination & Millennium development goals (MDGS)

The MDGs include the reduction of child mortality, improvement in maternal health, and
combating HIV/AIDS, malaria and other diseases. These all call for well-functioning health
systems, but are highly dependent on inputs from other sectors. For example, optimal public
power supply is required for the efficient maintenance of vaccine cold chains so as to
maintain the potencies of vaccines to reduce child death and for blood banks to provide blood
to save the lives of haemorrhaging women at delivery. Again, some other MDGs are also
related to the health sector. For example, eradication of extreme poverty and hunger
(associated with economic development and agricultural sectors) and ensuring a sustainable
environment (associated with environmental sector) produce health benefits. At least three
key points emerge from these observations. First, MDGs and their indicators are closely
related to PHC tenets, as exemplified by interventions related to maternal and child health,
water and environment and poverty eradication. Secondly, interventions developed in
response to the Alma -Ata Declaration on PHC more than 30 years ago were meant to be
urgent, and the MDGs are time-bound and now urgent, having well past mid-term. Thus,
MDGs appear to fast-track PHC, at least conceptually. Thirdly, while intersectoral

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coordination per se is not formally presented as an MDG strategy, it is required in that regard
as has been explained for health.6, 7

4.3) Intersectoral coordination & Health care advancement 8, 9, 10

Medical care forms only one part of health care. It comes into play when health deteriorates
and disease develops. Primary health care is concerned with health promotion, disease
prevention and then management of disease if it occurs. For achieving this, input from sectors
other than health is of paramount importance. Primary health care requires support of other
sectors such as:

Good nutritional status is associated with lower morbidity. Nutritional status can be
improved through development in agriculture and home economics. Agriculture sector
development can ensure sufficient amount of healthy food for the community.
Education sector: Women education and empowerment can improve their knowledge
about nutrition within available resources. The WHO global programme for health
promoting schools (WHO, 1996) has as one of its aims the increased involvement of
girls in education. This is a particularly important outcome not only for education but
also for health in low and middle income countries. Health promoting schools as a
settings approach to health is widely used across the world. It is a key example of
intersectoral collaboration between the health and education sectors
Availability of potable water can reduce morbidity and mortality, particularly among
infants and children. Efforts to bring safe water within easy reach of rural and urban
population will have positive effect on health of people.
Similarly safe disposal of waste and excreta improve health of people.
Housing that is adapted to local climatic conditions (healthful housing) has a positive
effect on health.
Road connectivity of remote villages will not only improve economic condition by
providing easy market access but also enable health, sanitation and education teams to
reach the rural areas. Transportation of patients to and from referral centres will be
facilitated. Supply of drugs to the health facilities can be regular.
Mass media will improve health education reach the needy, e.g. preventing mosquito
and fly breeding, importance of immunization etc. Also disaster warnings and
instructions to safeguard the health during disaster will minimize the loss of health.
Bringing about legislation affecting health and many other sectors affecting health can
improve the health status of people.

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Hence national development planning should be done by multidisciplinary team including
health administration. Also at the local level, developing the deficient sector for improving
health situation, can be achieved if only there is coordination between health sector and the
concerned sector/s.

4.4) Intersectoral coordination & Mental health promotion11

Mental health is a positive state of wellbeing, which contributes to effective functioning.

Mental health is influenced by varieties of social, economic, and environmental factors,
which are often referred to as social determinants of mental health. These determinants
include complex and intractable problems such as poverty, homelessness, unemployment,
abuse, and various other forms of social inequalities operating at different stages of life. Life
experiences across the life course also influence mental health. Mental health promotion is a
relatively new but rapidly growing component of health promotion. It involves a variety of
actions at individual and community level aimed to enhance wellbeing, quality of life, the
ability to cope with normal stresses of life, and to work productively and effectively. To
achieve success in mental health promotion, it is essential to involve the whole community
and develop partnerships and coordination between a range of agencies in the public, private,
and nongovernmental sectors, because mental health is influenced by various social
determinants. Mental health promotion requires the involvement of wide range of sectors and
players and an intersectoral as well as interdisciplinary framework.

5. APPROACHES TO INTERSECTORAL ACTION ON

HEALTH12

Many approaches for implementing intersectoral action on health exist. However, two
overall strategies for intersectoral action are as follows:

One general strategy is to aim to integrate a systematic consideration of health

concerns into all other sectors and routine policy processes, and identify approaches
and opportunities to promote better quality of life.
An alternative approach to the ambitious goal of formally including health in all
national policies is a narrower and more issue-centred strategy. Here the goal is to
integrate a specific health concern into other relevant sectors policies, programmes

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 and activities. Widespread adoption of the WHO Framework Convention of Tobacco
Control has made tobacco control an excellent example of this strategy.

6. STEPS TO IMPLEMENT INTERSECTORAL ACTION ON

HEALTH13
There are a series of steps that can be taken to initiate and succeed with intersectoral action
on health. The ten steps described below are relevant to both an issue-centred approach to
implementing intersectoral action on health and to a general strategy of achieving health in all
policies. The steps should not be seen as linear, but form part of a continuous cycle of
learning for improvement, and need to be adapted to every different context.
6.1) Self-assessment
Assess the health sectors capabilities, readiness, existing relationships with relevant sectors
and participation in relevant intergovernmental bodies. Strengthen the institution by
improving staff capacity to interact with other sectors (e.g. public health expertise, overall
understanding of public policies, politics, economics, human rights expertise), to effectively
address and communicate potential co-benefits and to contribute to the debate with other
sectors on health issues associated with policies not specifically targeting health.
6.2) Assessment and engagement of other sectors
Achieve a better understanding of other sectors, their policies, goals, language, values,
and priorities, and establish links and means of communication with them and assess their
relevance to the established health priorities.
Conduct a stakeholder and sector analysis. Identify opportunities and potential
governance structures to engage other sectors, and acknowledge the complexity of the
policy environment and health determinants. Explain to other sectors the health sectors
interest in their involvement and vice versa.
Identify existing intersectoral bodies, laws, mandates for intersectoral action and public
health, executive orders, constitutional mandates, and human rights instruments that can
support intersectoral actions.
Set a regular/periodic mechanism to maintain and strengthen the intersectoral
engagement.
6.3) Analyze the area of concern
Define the area of concern and the intervention needed in terms of determinants of health
and intersectoral approach, and analyse the context with regards to available mechanisms,
opportunities, interests, and politics.

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 Present sector-specific disaggregated data focusing on the impact on other sectors and
analyse the feasibility of the intervention.
Build the case using disaggregated data to describe how policies in the sector of interest
affect health, making clear the mechanisms that lead to health impacts (e.g. occupational
risks, pollution, employment, health care costs, and transportation time) including health
equity.
Establish systematic way to review the implications of specific policies and actions, and
propose ways these can be changed to promote health co-benefits.
6.4) Select an engagement approach
Gauge the intensity of engagement with other sectors in terms of health impact, health
priorities, overall public policy priorities, common interests, and the strategic relevance of the
relationship with the sector. There are three general approaches:
Issue approach: identify sector policies that have a major impact on public health
priorities (e.g. policies that can reduce cardiovascular diseases).
Sector approach: Identify the sectors with policies that are most likely to impact health
(and contribute to public health gain).
Opportunistic approach: Select issues, policies or sectoral alliances based on the
objective of early impact on health and early success for all involved parties.
6.5)Develop an engagement strategy and policy
After defining and analysing the problem and selecting an engagement approach, develop a
strategy to involve the relevant sectors. The strategy should consider adequate long-term
commitment, time allocation, supporting champions with tools and guidance, establishing
common points of interest and concern with the other sector, and identifying strategies that
are agreeable to all parties.
6.6)Use a framework to foster common understanding between sectors
A key factor for successful intersectoral action is the ability to identify a common
understanding of the key issues and required actions to address them. This can be aided
through the use of a common framework to facilitate a shared understanding of the causal
pathways and key intervention points. An essential aspect of such a framework is that it takes
a broad view of health and the various health determinants and includes specific reference to
health inequities. A framework helps facilitate discussions with other sectors, inform the
selection of interventions and ensure a common plan of action that has measurable ways of
assessing the interventions design, implementation and evaluation.

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6.7) Strengthen governance structures, political will and accountability
mechanisms
Based on an analysis of the political context, and expected support and opposition from
different stakeholders, assess the political route required to adopt the policy. The strategies
and actions depend on the context for the specific issue that is being promoted; therefore the
political alternatives are very diverse. Existing or new governance structures are tools to
ensure successful intersectoral action.
6.8) Enhance community participation
Enhance community participation in the policy development and implementation process
through:
Public consultation
Disseminating information using mass media
Web-based tools
Facilitating the involvement of NGOs from different sectors in the policy-
making process.
Effective public engagement requires more than a one-off effort during the policy design
phase. Adequate and continuous disclosure of information and the creation of feedback
channels to convey concerns and potential grievances once the policy has been implemented
are essential to sustaining community participation and ensuring accountability for actions
taken.
6.9) choose other good practices to foster intersectoral action
Join other sectors in establishing common policies/programmes/initiatives with joint
reporting on implementation (e.g. compliance with human rights standards), explicit
principles to be followed such as transparency, stakeholder participation, and with common
targets.
Provide expertise required by other sectors (e.g. policies on indigenous people, migration,
health care, health economics, health determinants or social inequalities). Provide tools and
techniques to include health in the policies of other sectors and to address health inequalities.

Allocate available resources to contribute to other sectors policy implementation and share
lessons in terms of successful implementation of policies in similar contexts. Use each
sectors regulatory capabilities to have an impact on health or to accomplish other common or
public objectives.

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6.10) Monitor and evaluate
Follow closely the implementation of intersectoral action through monitoring and evaluation
processes to determine the progress in achieving planned outcomes. This is a process that
requires continuous learning for reinforcement of good practices and learning from failures.
Report regularly on the development of policies that protect and promote health, and on the
health impacts of policies in key sectors.

7. EXAMPLES OF INTERSECTORAL ACTION ON HEALTH

IN INDIA
7.1) Intersectoral approach to National Tobacco Control14, 15
The estimated number of adult tobacco users in India is 274.9 million, with 206 million users
of only smokeless tobacco. Prevalence of overall tobacco use among males is 48% and that
among females is 20%. The myriad ways in which tobacco is produced, marketed and
consumed further add to the complexities of tobacco control. Intersectoral action for health
has contributed to the implementation of the WHO Framework Convention on Tobacco
Control (WHO FCTC) in India and thereby offers insights for Health in All Policies.

The WHO FCTC, ratified by the Government of India in 2004, provides the foundation to
manage tobacco control programmes and request the cooperation of related sectors. A high-
level governance structure that was created, the National Tobacco Control Cell, was
established in the Ministry of Health and Family Welfare in collaboration with WHO country
Office for India for overall policy formulation, planning, monitoring and evaluation of the
different activities envisaged under the programme. Every state has a State Tobacco Control
Cell, which is responsible for planning, implementation and monitoring at state level. To
drive the implementation of the WHO FCTC by different sectors, high level coordination
committees have been established at national, state and district levels.

The Ministries that have contributed towards tobacco control at national and state level
include: Ministry of Human Resource Development, Ministry of Information and
Broadcasting, Ministry of Home Affairs, Ministry of Labour, Ministry of Railways and
Ministry of Finance. In addition Parliament, judiciary, civil society and media have also been
significant allies for the advancement of tobacco control in India. Preliminary work is
underway with the Ministry of Agriculture, Ministry of Labour, Department of Rural

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development and Ministry of Environment and Forest for working out strategies to provide
alternative livelihoods for those engaged in bidi rolling, tendu leaf plucking and tobacco
cultivation.

The experience of the Tobacco Control programme with intersectoral action was that, low
levels of involvement of other ministries and the perception that tobacco control is the
mandate of the ministry of Health alone. They are being addressed through advancing
mechanisms for advocacy and dialogue with stakeholders, including training. Sensitization
and training workshops on key topics are held regularly to help multisectoral
stakeholders/ministries understand their role and how to implement the provisions of WHO
FCTC.
Through the various processes described above, India has been able to achieve varying levels
of compliance on most of the key provisions of WHO FCTC. New policy initiatives have
come into force on prohibition on sale of tobacco to minors and around educational
institutions, imposing restrictions on tobacco imagery in films and TV programmes and ban
on smokeless tobacco products like gutka (chewed tobacco). Some states, cities and villages
have come forward and declared their jurisdictions as smoke-free and tobacco-free. The
continued roll-out of and enforcement of these new initiatives will continue to rely on
cooperation and collaboration across sectors, as well as the different levels of government,
supported by appropriate advocacy and training.
7.2) school sanitation and hygiene education in India16
School is important for cognitive, creative and social development of children. So the school
Sanitation and Hygiene Education, necessary for the safe, secure and healthy environment for
children to learn better and face the challenges of future life. This understanding is very much
a part of the policy of Government of India. From policy to programme, School Sanitation
and Hygiene Education (SSHE) has now become a reality of school centric development
action being realized by most of the schools. Government of India has launched this
programme integrating with broader sanitation program to ensure that all the schools
especially rural schools in the nation have basic sanitation and drinking water facilities and
good hygiene practices are taught to the children. The SSHE programme is participatory in
nature and an important component of the national reforms programme for rural water and
sanitation sector. Many of the challenges, which the programme in India faces, are similar to
those of other countries. Approach, strategy, and mode of implementation may differ but the

10
vision associated it remains the same. Sharing these may offer insights and serve as a starting
point for cross-learning and further improvement of the programme
7.2.1) Intersectoral coordination
SSHE is an integrated intervention involving various cross-cutting areas, which range from
involvement of community participation, construction-related issues, health checkups,
hygiene education, operation & maintenance, monitoring, funding and institution building.
These issues are very diverse and complex in the context of involvement of various sectors
such as Water Supply, Heath and Family Welfare, Panchayati Raj and Rural Development,
Public Health Engineering, Women & Child Development, Education etc. All these make
intersectoral coordination very important and relevant to effectively implement the SSHE. It
implies that the SSHE programme is given sufficient priority and the involved departments
demonstrate commitment by extending support for the implementation of their respective
components of SSHE. This may include the provision for funds, technical assistance,
infrastructure and institutional support, motivation and supervision of staff, etc. Secondly,
coordination must ensure that both software and hardware component of the SSHE
programme are well balanced and integrated for effective implementation.

The intersectoral coordination is essential at all the levelsfrom state, district, block and
village to school levelso as to improve the school environment and students hygiene
behaviour. This requires the concerned ministries and departments to join hands and avoid
duplication of efforts. In this context, the Department of Drinking Water Supply has taken
several initiatives to build a strong coordination with the concerned departments such as
Department of Elementary Education & Literacy, Department of Health, and Department of
Women and Child Development, Ministry of Tribal Affairs, Ministry of Social justice and
Empowerment to ensure priority to the SSHE programme.

For example, with the Department of Elementary Education and Literacy, a joint action plan
for funding has been proposed on the coverage of water and sanitation facilities in uncovered
schools. On technical support front, coordination has been forged on the training of teachers
on hygiene education, curriculum development etc. A joint monitoring is also planned for
regular follow up for improvement and effectiveness of the programme. Similarly, with the
Department of Health, coordination covers provision of health services such as regular health
checkups and de-worming, health index card for school children, etc. Although, the national
water supply programme was launched during the First Five-Year Plan as part of

11
governments health sector, the linkages were lost along the way. Institutional interface
between departments dealing with Water Supply & Sanitation and Department of Health &
Family Welfare needed coordination that has been revisited in year 2004 again to extend
health services to school.

7.3) Intersectoral coordination for organizing National immunization day

programme

Tremendous progress has been made since polio eradication activities were first introduced in
1995. From the beginning of the polio eradication initiative, India has been the worlds
largest polio endemic country. Before the introduction of National Immunization Days
(NIDs) in 1995, an estimated 35,000 children were paralysed by polio in India each year.
Significant reductions in cases were seen mainly as a result of the implementation of NIDs in
the following years, but in 2002, 1600 cases were reported in a major outbreak that originated
in western Uttar Pradesh (UP) and spread into many other states most of which had been
polio free for more than one year.

7.3.1) Involvement of stakeholders to implementing NIDs programme

Education sector

Polio booths may be located in schools/colleges .

School teachers/ college students can be part of booth and house to house vaccination
teams and/or accompany the teams during their house to house visits.
School children/college students should take out rallies in support of the programme
prior to the NIDs and on days of activity.
Schools should develop an army of school children who will identify target children
in their neighbourhoods and bring them to the booths.
Schools should display posters in support of the programme

Social Welfare

Polio booths may be located at ICDS centres.

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 ICDS workers must be part of vaccination teams.
Anganwadis should distribute and display materials like handouts, posters and
banners in their neighbourhood.
ICDS workers should help in contacting local community leaders/mothers groups to
raise community awareness about NIDs

Panchayati Raj Institutions

Help to identify and provide suitable locations for booths.

Help in creating community awareness about the programme.
Gram Panchayat Vikas Adhikari (Village development secretaries), Lekhpals, Village
Pradhans and Panchayat members should accompany vaccination teams during
house-to-house visits and mobilize community to accept OPV. Their participation is
crucial in conversion of houses and in areas with resistance to acceptance of OPV.
Give feedback on completion of activities in their areas.

Railways, Surface transport, Civil aviation, Shipping

Departments should allow setting up of Transit booths on all railway platforms/ bus
terminals /highways /ferry crossings/airports/ports during booth and house-to-house
activity days. Where ever required these booths should function 24 hours, during the
days of activity.
Railway health staff should vaccinate all target children in railway staff colonies.
OPV should be provided in selected trains linking endemic areas of the country by
railway health staff.
Polio spots should be shown on closed circuit TV at all railway stations/bus
terminals/airports before and during the activity.
Polio hoardings should be displayed on all railway coaches, railway stations, and
bridges to create awareness

Other Government department

Government workers may be part of vaccination teams and at least help to cover their
own residential colonies.
Government offices should display materials like posters and banners.
Police wireless may be used to convey urgent NIDs messages.

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 Concerned departments should allow the key messages of NIDs programme to be
printed on telephone, electricity and water bills.
Telephone exchanges may be requested to play messages regarding the programme
when subscribers make or receive telephone call.

8. KEY LESSONS LEARNT ON INTERSECTORAL ACTION

ON HEALTH18

A capable and accountable health sector is vital to promote and support

intersectoral action. The health sector should facilitate the process as appropriate,
ensure the early involvement of other policy sectors in the policy-making process and
be flexible to adapt its role at various stages in the implementation of intersectoral
action ( ISA).
Establishing a common information system with sector-specific data can shed light
on opportunities for intersectoral action and increase accountability by enabling
analysis of policies and monitoring of outcomes. Existing data and information
systems should be used and built on if available.
Policies selected for implementation through intersectoral mechanisms need to
be robust, feasible, based on the evidence, oriented towards outcomes, applied
systematically, sustainable, and appropriately resourced.
Community participation and empowerment in the process of policy-making, from
the initial stage of assessment to evaluation of the intervention and monitoring of
outcomes, are critical to focus attention on the needs of the people.
MDGs as a mechanism to promote intersectoral action with a special focus on the
impact of determinants of health and health equity can be useful tool in increasing the
accountability of other sectors for health outcomes.

Context-appropriate application of Health Impact Assessment can help to

promote intersectoral action for health. The potential of integrated impact assessments
should be considered.
A human rights-based approach can help address the underlying social and
environmental determinants of health and the need for multi-sector involvement.
Assessment, monitoring, evaluation, and reporting are required throughout the
whole process, Proper assessment of the problem, its determinants and social,
political and cultural context are crucial to frame the issue and benefits to various

14
 sectors. Regular monitoring and evaluation of health impacts is required to maintain
focus on outcomes and identify the strengths and of interventions.

9. AREAS WHERE INTER SECTORAL COORDINATION IS

ENVISAGED BY 10TH PLAN19, 20
Education Department in Behaviour change communication (BCC) messages on
reproductive and child health care, female literacy and employment, raising the age at
marriage, generating more income in rural areas, improving the nutritional status of
women and children.
Blood safety: making safe blood available at all appropriate facilities.
Management of RTI/STI through specialized and improved service delivery at
public health facilities, training doctors and the provision of drugs to treat RTI/STIs.
Prevention of Parent to Child Transmission (PPTCT) has a key linkage with
pregnant women.
Weighing each child monthly, including neonates, recording the weight on the growth
card, using referral card to send mothers and children to the Sub-center or PHC,
maintaining child cards for children below six years and discussing these with
visiting medical and para-medical staff.
Carrying out quick sample census of all the families, especially pregnant women,
mothers and children in those families in their area.
Providing health and nutrition education to mothers including home based care for
new born babies.
Visiting homes to educate parents to improve their child's growth and development
particularly for children attending the anganwadies.
Assisting ANMs and PHC staff in the health component of the reproductive and
child health (RCH) II (e.g. immunisation, health and antenatal checkups, safe
delivery).
Becoming depot holders for contraceptives, ORS, Vitamin A, delivery kits.
Maintaining records of the immunisation status of children and pregnant women, in
her area.
Supporting ANMs in preparing Annual Plans under the Community Needs
Assessment Approach.
Acting as a focal point in the village for Maternal and Child Health.
Maternity Huts to be built at Sub-Center under the Rural Housing Scheme.
Connectivity to Rural Primary Health Infrastructure to be adopted as criteria for
schemes under Prime Minister Gram Sadak Yojana.
BCC assistance at block level for water purification.

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 Development of training modules for members of Panchayati raj institutions,

identification of training Institutions and trainers etc.

Dissemination of information about the schemes and initiative of department of

family welfare through newsletter of both departments.

A joints working group of ministry of Human resource development and ministry of
human and family welfare to come up with a composite educational drive, which will
combine the aspects of raising the literacy level of girl and girl child and imparting
the awareness of the family welfare programs in the educational curricula.
Utilizing Nehru Yuva Kendra for imparting family life education to out-of-school
adolescents.
Family life modules to be used as primers for adult literacy program.
Introduction of family life module in syllabus for 10th and +2 class.

10. ROLE OF GOVERNMENT IN ENABLING INTERSECTORAL

COORDINATION TOWARDS PUBLIC HEALTH ISSUES21

The Ministry of Health needs to form stronger partnerships with other agents involved in
public health, because many factors influencing the health outcomes are outside their direct
jurisdiction. Making public health a shared value across the various sectors is a politically
challenging strategy, but such collective action is crucial.

10.1) Living conditions

Safe drinking water and sanitation are critical determinants of health, which would directly
contribute to 70-80% reduction in the burden of communicable diseases. Full coverage of
drinking water supply and sanitation through existing programs, in both rural and urban
areas, is achievable and affordable.

10.2) Urban planning

Provision of urban basic services like water supply and solid waste management needs
special attention. The Jawaharlal Nehru National Urban Renewal Mission in 35 cities works
to develop financially sustainable cities in line with the Millenium Development Goals,
which needs to be expanded to cover the entire country. Other issues to be addressed are
housing and urban poverty alleviation.

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10.3) Revival of rural infrastructure and livelihood

Action is required in the following areas: Promotion of agricultural mechanization, improving

efficiency of investments, rationalizing subsidies and diversifying and providing better access
to land, credit and skills.

10.4) Education

Elementary education has received a major push through the Sarva Siksha Abhayan. In order
to consolidate the gains achieved, a mission for secondary education is essential. Right of
children to free and compulsory education Bill 2009 seeks to provide education to children
aged between 6 and 14 years, and is a right step forward in improving the literacy of the
Indian population.

10.5) Nutrition and early child development

Recent innovations like universalization of Integrated Child Development Services (ICDS)

and setting up of mini-Anganwadi centers in deprived areas are examples of inclusive growth
under the eleventh 5-year plan. The government needs to strengthen ICDS in poor-
performing states based on experiences from other successful models, e.g., Tamil Nadu
(upgrading kitchens with LPG connection, stove and pressure cooker and electrification; use
of iron-fortified salt to address the burden of anemia). Micronutrient deficiency control
measures like dietary diversification, horticultural intervention, food fortification, nutritional
supplementation and other public health measures need intersectoral coordination with
various departments, e.g., Women and Child Development, Health, Agriculture, Rural and
Urban development.

10.6) Social security measures

The social and economic spinoff of the Mahatma Gandhi Rural Employment Guarantee
Scheme (MREGS) has the potential to change the complexion of rural India. It differs from
other poverty-alleviation projects in the concept of citizenship and entitlement. However,
employment opportunities and wages have taken the center stage, while development of
infrastructure and community assets is neglected. This scheme has the necessary manpower
to implement intersectoral projects, e.g., laying roads, water pipelines, social forestry,

17
horticulture, anti-erosion projects and rain water harvesting. The unlimited potential of social
capital has to be effectively tapped by the government.

10.7) Food security measures

Innovations are required to strengthen the public distribution system to curb the inclusion and
exclusion errors and increase the range of commodities for people living in very poor
conditions. It is essential that the government puts forth action plans to increase domestic
food grain production, raise consumer incomes to buy food and make agriculture
remunerative.

10.8) Other social assistance programs

The Rashtriya Swasthiya Bima Yojana and Aam Admi Bhima Yojana are social security
measures for the unorganized sector (91% of India's workforce). The National Old Age
Pension scheme has provided social and income security to the growing elderly population in
India.

10.9) Gender mainstreaming and empowerment

Women-specific interventions in all policies, programs and systems need to be launched. The
government should take steps to sensitize service providers in various departments to issues
of women. The Department of Women and Child Development must take necessary steps to
implement the provisions of Protection of Women from Domestic Violence Act, 2005.
Training for protection officers, establishment of counselling centres for women affected by
violence and creating awareness in the community are vital steps. Poverty eradication
programs and microcredit schemes need to be strengthened for economic and social
empowerment of women.

10.10) Reducing the impact of climate change and disasters on health

Thermal extremes and weather disasters spread of vector-borne, food-borne and water-borne
infections, food security and malnutrition and air quality with associated human health risks
are the public health risks associated with climate change. Depletion of non-renewable
sources of energy and water, deterioration of soil and water quality and the potential
extinction of habitats and species are other effects. India's National Action Plan on Climate

18
Change identifies eight core national missions through various ministries, focused on
understanding climate change, energy efficiency, renewable energy and natural resource
conservation.

The Ministry of Health, in coordination with other ministries, provides technical assistance in
implementing disaster management and emergency preparedness measures. Deficient areas
include carrying out rapid needs assessment, disseminating health information, food safety
and environmental health after disasters and ensuring transparency and efficiency in the
administration of aid after disasters. Implementation of Disaster Management Act, 2005 is
essential for establishing institutional mechanisms for disaster management, ensuring an
intersectoral approach to mitigation and undertaking holistic, coordinated and prompt
response to disaster situations.

10.11) Governance issues

In order to ensure that the benefits of social security measures reach the intended
sections of society, enumeration of below Poverty Line families and other eligible
sections is vital. Check mechanisms to stop pilferage of government funds and
vigilance measures to stop corruption are governance issues that need to be attended.
The government should take strict action in cases of diversion of funds and goods
from social security schemes through law enforcement, community awareness and
speedy redressal mechanisms. Social audits in MREGS through the Directorate of
Social Audit in Andhra Pradesh and Rajasthan are early steps in bringing governance
issues to the fore. This process needs strengthening through separate budgets,
provisions for hosting audit results and powers for taking corrective action. Similar
social auditing schemes can be emulated in other states and government programs like
ICDS, which will improve accountability and community participation, leading to
effective service delivery.

11. BENEFITS OF INTERSECTORAL COORDINATION

To provide sustainable basic health services to the community.

Early detection and treatment of patient within the community itself.
To promote cooperation and mutual understanding among various sectors.
To take the pressure off one sector alone.
For attaining the goal of Health for all.
To make the services available to people with early and easy access22

19
12. CHALLENGES IN INTERSECTORAL ACTION FOR
HEALTH

23
Fig.1.Challenges in intersectoral coordination

13. MEASURES TO OVERCOME CHALLENGES23

To involve other sector during planning and developmental strategic plan and
policies guideline.
Each district need to have a specific district frame work and budget for
intersectoral activities.
The authorities should introduce quarterly meeting to review the activities and
identify those that could be modified and implemented in an intersectoral
approach.
Creation of awareness and advocacy for political support, provision of human
and political resources, sharing of expertise, formulation and coordination of
policies.

20
 Sensitization and training workshop on key topic can be held regularly to help
multisectoral stakeholder/ministries to understand the role and how to
implement the program.

14. CONCLUSION

Intersectoral action for health is seen as central to the achievement of greater equity in health,
especially where progress depends upon decisions and actions in other sectors, such as
agriculture, education, and finance. A major goal in intersectoral action is to achieve greater
awareness of the health consequences of policy decisions and organizational practice in
different sectors, and through this, movement in the direction of healthy public policy and
practice. Increasingly intersectoral coordination is understood as cooperation between
different sectors of society 23

15. REFERENCES
1. WHO. Declaration of Alma-Ata. International Conference on Primary Health Care,
Alma-Ata, USSR, 6-12 September 1978.

2. WHO (1997) Intersectoral action for health: a cornerstone for health-for-all in the
twenty-first century. Proceedings of International Conference on intersectoral Action
for Health. World Health Organization, Halifax, Canada, April 1997.

3. The role of intersectoral cooperation in national strategies for health-forall.Geneva,

World Health Organization, 1986 (A39/Technical Discussions/2)

4. . WHO. Intersectoral action for health: a cornerstone for health-for-all in the twenty-
first century. In: Proceedings of International Conference on Intersectoral Action for
Health; April 1997; Halifax, Canada. World Health Organization

5. WHO (1978) Declaration of Alma-Ata. Proceedings of the International Conference

on Primary Health Care. Geneva, Switzerland, 1978.

6. Mkandawire T: Targeting and universalism in poverty reduction. 2005, Geneva,

Switzerland: United Nations Research Institute for Social Development, Social Policy
and Development Program Number 23.

7. World Health Organization, Canadian Public Health Association. Intersectoral action

for health: a cornerstone for health for all in the 21st century. WHO/PPE/PAC/97.6:
Report of the International Conference. World Health Organization. 1997.

21
8. https://www.ncbi.nlm.nih.gov NCBI Literature PubMed Central (PMC).

9. www.hst.org.za/publications/intersectoral-working

10. https://www.thl.fi/web/thlfi-en/topics/.../health-in-all.../intersectoral-collaboration

11. Fazel M, Doll H, Stein A: A school-based mental health intervention for refugee
children: an exploratory study. Clinical Psychology. 2009, 14: 297-309.

12. CSDH: Closing the gap in a generation: health equity through action on the social
determinants of health. 2008, Geneva: World Health Organization. Final Report on the
Commission on Social Determinants of Health.

13. Marmot M, Friel S, Bell R, Houweling TA, Taylor S: Closing the gap in a
generation: health equity through action on the social determinants of health. Lancet.
2008, 372: 1661-1669.

14. WHO. Guidelines for controlling and monitoring the tobacco epidemic. World
Health Organization, Geneva. 1998.

15. Erickson AC, Mckenna JW, and Romano RM. Past Lessons and New Uses of the
Mass Media in Reducing Tobacco Consumption. Public Health Reports, 1990, May-
June;105(3): 239-44

16. Report of The Independent commission on health in india.Voluntary health

association of india.New Delhi.1997.

17. Baru, R. Private Health Care in India: Social Characteristics and Trends.
NewDelhi: Sage Publications.1999

18. WHO & PHAC (2008) Health Equity through Intersectoral Action: An
Analysis of 18 Country Case Studies. World Health Organization, Public Health
Agency of Canada.

19. National Commission on Macroeconomics in Health. 2005. New Delhi: Ministry of

Health and Family Welfare, Government of India

20. . Kishore.J. National Health Programmes of India.11th edition.New Delhi.

Century publication.2005. p.219-220

21. WHO. Intersectoral Action for Health: A Conference for Health-for-All in the
Twenty-First Century. Halifax, Nova Scotia,Canada, 22-23 April 1997.

22. Shabeer.P.Basheer.S.Yaseen Khan.Text book of advanced nusing practice.

Bangalore.Emees medical publishers.2012.p 99-100.

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 23. World Health Organization: Equity Team definition. Health and Human Rights and
Equity Working Group Draft Glossary Unpublished 2005. 2005 cited by Solar O,
Irwin A: A conceptual framework for action on the social determinants of health.
2010, Geneva: World Health Organization.

16. APPENDICES

1.TITLE; Is there any intersectoral coordination between health and education

department at primary health center level8
Authors; Sundar M, Boraiah G, Patel NG, Khan R.

Source; Indian journal of public health

Abstract
One of the principles of primary health care is intersectoral co-ordination. A cross sectional
study done at the primary health center revealed existence of unsatisfactory co-ordination
between health and education department.

According to the 1991 census, more than half of India's population is illiterate. In this
context, education can have an enormous effect upon health. Efforts need to be taken to
incorporate the principles and practice of good health among school-goers at all levels. 106
teachers of mean age 40 years from 52 schools and 21 health staff of mean age 30 years from
K. Gollahally, Primary Health Center area, Bangalore urban district, were interviewed to
assess their health-related knowledge, attitudes, and practice. Although 70 (66%) teachers had
heard of the Health for All by the Year 2000 slogan, only 32 could satisfactorily explain what
the slogan means. 46% of teachers and 50% of health staff were aware of intersectoral
coordination (ISC). All teachers and 90% of health staff favor ISC and believe that education
improves health and that health improves education. All teachers endorse cleanliness at
school, general personal hygiene, and the provision of recreational facilities, but only 45%
had been taught about such topics. 50% of teachers could satisfactorily explain why children
should be immunized, and the majority of teachers believe that a nutritious diet is needed to
promote health or for specific protection or both. Teachers were poorly informed regarding
health and although the study participants were aware of the need for ISC, they did not
regularly attend primary health care/school meetings
2. Improved school-based de-worming coverage through intersectoral
coordination: The Kenya experience8
authours; Dr Tigest Ketsela, ; Dr Davison Munodawafa, ; Dr Chandralall Sookram and Mr
Peter Phori; and Dr Eugenio Villar

23
Abstract

A national faecal examination of 27 729 schoolchildren from 395 schools carried out in 2008
indicated that intestinal parasitic worms affected an estimated five million (56.8%) children
in Kenya. Existing evidence shows that worm infections lead to reduced literacy levels due to
impaired growth and physical fitness. Existing evidence also shows that improved health
status leads to increased productivity, educational performance, life expectancy, savings and
investments, and decreased debts and expenditure on health care. Studies in the United States
have shown that worm infections lower literacy levels by 13% and lower earnings later in life
by 43%. Research in western Kenya showed that school-based mass deworming (SBD)
reduced school absenteeism by 25%. The School Health and Nutrition Programme of the
Ministry of Education (MOE) and the Ministry of Public Health and Sanitation (MOPHS)
launched a nationwide schoolbased deworming programme targeting all 22 000 public
primary schools in the country in 2009. The Kenya Medical Research Institute (KEMRI)
undertook extensive mapping surveys, using Geographic Information System (GIS) and
established worm prevalence levels in 135 districts with a high population density appropriate
for mass treatment. WHO recommends mass deworming in areas where the prevalence of
worm infection soil-transmitted helminthes (STH) is above 50%. This report outlines the
coordination and partnership between two key ministries (Education and Public Health) in
Kenya, other line ministries, the private sector, NGOs and the community in implementing
the first phase of a sub-national school-based deworming exercise. The areas targeted
included Coast, Central, Western, Nyanza and parts of Eastern provinces, covering over 45
districts in this first phase. The SBD programme is guided by the National School Health
Policy and Guidelines launched in 2009. Two crucial national committees coordinate the
SBD: the School Health Inter-agency Coordinating Committee (SH-ICC) responsible for
social and resource mobilization and coordination and the National School Health Technical
Committee (NSHTC), which coordinates technical aspects of school health activities. The
planning and implementation of SBD at the district level was done through the district
multisectoral committees. The committee membership include government line ministries of
Education, Public Health and Sanitation, Medical Services, Water and Irrigation, Local
Government and Internal Security. Development and UN partners included WHO, the World
Bank, DFID, UNICEF, GTZ, JICA, AMREF and USAID among others. The school
management committees (SMC) include parents, teachers, pupils and community
representatives. Training for the teachers was done through the National Master Trainers
(MT). The teachers were responsible for administering the deworming tablets and providing
health education to parents and pupils in their respective schools. Over 1000 districts,
divisionlevel personnel and 16 000 teachers were trained on deworming activities at the end
of this phase. Most importantly, 3.5 million children from 8000 schools were dewormed. The
programme recorded a huge success (70%) in terms of scope and was extremely Improved
School-Based Deworming Coverage Through Intersectoral Coordination: The Kenya
Expereince vi cost-effective. The deworming programme had an overall cost of
approximately US$ 0.3 per child per year. This exercise also resulted in the introduction and
integration of other school health programmes such as water, sanitation and hygiene, values
and life skills and school meals, which were implemented through the same existing

24
structures that complement the deworming programme. This has also ensured sustainability
of the deworming programme.

3. MENTAL HEALTH PROVISIONS IN SCHOOLS OF KERALA:A NARRATIVE

OVERVIEW OF PROGRAMS AND INTERVENTIONS8
Author-Ramkumar
Psychiatry Specialist, Caritas Hospital, Kottayam

Source; Indian journal of psychiatry

ABSTRACT

In recent years, many interventions that specifically focus on mental well being of children
are being made available in schools of Kerala. This paper is a narrative overview of the major
school-based mental health interventions currently being implemented in the state. Fifteen
programs, selected after applying certain screening procedures, are analyzed using the
Institute of Medicine (IOM) frame work. These services are being provided by multiple
agencies from different governmental sectors, nongovernmental sector and private sector, and
overall developments in the state parallel the developments happening in mental health
scenario in schools of high income countries. Nine programs had universal prevention as a
component, and the components of selective and indicated prevention were present
respectively in three and eight programs. The personnel delivering indicated interventions
were minimally trained and had received little specialist guidance. Many programs allude to
referral to specialist professionals, but without any clear delineation of the care pathway.
There are indications of a lack of coordination between the various programs, precluding
synergy of work and efficient fund utilization. The DMHP could fill the service gap by
facilitating and coordinating selective and indicated prevention programs in our schools.
Creation of a nodal agency within the Education Department itself, with mandate for inter
sectoral coordination, could be a way ahead in integrating the programs and in ensuring
universal access and quality of the intervention.

Keywords: school mental health, Kerala, children

4.Inter-sector Coordination for Sustainable Solutions of Arsenic Contamination of

Ground Water in India: An Explorative Study18

AUTHOR- Atanu Sarkar

SOURCE-Indian journal of public health

ABSTRACT
Around nine million people living in India are at risk by consuming arsenic contaminated
water. While several technological solutions failed to address the problem, magnitude of
suffering of the people has increased over the period. The study aims to find out the solutions,
which are effective, feasible, locally acceptable, and ecologically appropriate. Data were
collected through in-depth study, focus group and informal discussion from the households of
arsenic affected villages and by review of literature, policy documents, interaction with
concerned authorities and technical experts. The study shows that the current policies need

25
collective thinking, community participation and bottom-up action to deliver effective
sustainable solution. Modern output driven agricultural policy has led to destruction of
traditional mode irrigation and water conservation and over exploitation of groundwater,
which triggered arsenic contamination and hence human exposure. The study shows that for
sustainable solution, inter-sector approach including the management of agriculture, water,
health, ecology to be effectively implemented and integrated. Gradual reduction of
groundwater dependence, along with effective management of surface water as an alternative,
would be the major step to bring down further contamination and exposure. Introduction of
new variety of seeds, which require less water, can reduce dependence on ground water. More
emphasis is also needed to improve the support system in terms of quality and accessibility of
health care and rehabilitation services of the chronically debilitating sufferers, to reduce
further disease burden and economic loss. Arsenic filters could provide temporary respite, but
not recommended for long-term solution, due to ecological impact of highly toxic sludge to
be generated from the filters. Rainwater harvesting can be a viable alternative solution as
arsenic affected areas belong to moderate to high rainfall zone.

Key words: Arsenic, irrigation, sustainable development, community mobilization, disparity

26