Achieving collaboration for resilient ‘health systems’

3 November 2016

It may seem obvious to state: a resilient health system requires involvement and commitment from a range of sectors that sit outside health. In turn, the natural assumption is that to build a strong health system needs the collaboration and integration of a wide range of stakeholders and sectors. However, achieving this is no mean feat, so where do we begin?

Importance of collaboration

The idea of multisectorality is not new. There have been at least two prominent strands of discourse within public health that have advocated for collaborating with stakeholders outside health. 

First, is the body of work around social determinants of health. This was prompted by a series of studies in early 90s that identified the importance of non-health factors in influencing public health outcomes. This prompted interest in the field of social epidemiology and resulted in a high level commission on social determinants convened by World Health Organization (WHO). This research has been widely cited in the currently ongoing debates around social inequalities and has been central to a call for inclusion of Health in All Policies (HiAP) by the WHO. The concept of HiAP advocates for intersectoral action for health and a consideration of health impacts in the decision of non-health sectors.

Another discussion stream highlighting importance of multisectorality in health was prompted by threats perceived around epidemic-prone diseases emerging from livestock and wildlife, such as the global spread of SARS and avian flu in the early 2000s. Due to close animal-human connections in disease emergence and spread, ecologists, veterinarians and ID communities made a call for animal and human health systems to work closely under a ‘One Health’ umbrella. 

To clarify, the idea of multisectorality is not unique to these social determinants of health and infectious diseases streams; public health nutritionists for one have been advocating for a collaboration among agriculture, food processing and health sectors for a long time. Indeed, commentators on global health governance (pdf) have been advocating for a more pluralistic (pdf) mechanism for the same. 

Barriers to collaboration

However many of these collaborations never really took off and were not able to meet even the modest targets they had set for themselves, as my work on zoonoses highlights and examines. In the absence of an overarching vision and the overwhelming focus on human health priorities over other sectors have proven to be a major hurdle towards developing sustainable collaborations housed in health sector. 

In specialised bureaucracies, where rigid departmental functioning is the norm, multisector collaborations cannot develop on their own. Instead, collaborations tend to develop out of practical concerns when there is a strong felt need on the ground. 

Not surprisingly, a lot of work on multisector collaborations has been done by political scientists who look at the functioning of public institutions. This work argues convincingly, that collaborations occur when a set of pre-conditions are fulfilled and are comprised of autonomous, self-organising agents using shared norms. 

Some have demonstrated how multi-institutional collaborations can lead to increased adaptive capacity of governance systems (such as by building and increasing diversity of inputs and resources, building redundant capacity, and engaging in transformative learning). 

This clearly shows that engaging with diverse group of stakeholders (from multiple sectors and having different interests) is integral for developing successful collaborations. 

How to build resilience through collaborations

As stated, collaborations are not a natural occurrence, but emerge from crisis events when the individual actors are likely to collapse if they do not come together. Their interdependence is not because of shared objectives; rather, it is propelled by a complementary worldview and capacities.  

It is not necessary for collaborating actors to agree on same goals as long as they all get what they want out of their partnership. And central to the conceptualisation of resilience in complex adaptive systems, is the fact that collaborations can only succeed by prioritising innovations and responsiveness through more flexible reporting lines and learning systems instead of regimented approaches to partnerships that are characterised by ring-fencing of goals and hierarchies of disciplines (think nutrition or One Health). 

Most importantly, perhaps, for collaborations to succeed and sustain, the end goal should not be mere accomplishments of short term outputs, rather they should be working towards transforming themselves and their parent systems with changing conditions and requirements. 

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