Richard Skolnik , MPA

2. Richard Skolnik, MPA Lecturer, Yale School of Public Health and the Yale School of Management Director for Health and Education (South Asia Region) at the World Bank Vice President for International Programs at PRB Director of the Center for Global Health at The George Washington University Executive Director of the Harvard PEPFAR program

3. Objectives • To consider the importance of intersectoral approaches to addressing key global health issues • To exchange ideas about enabling students to understand how intersectoral approaches are essential to improving global health

4. Main Messages • Most global health issues require intersectoral action – often by the MOH in collaboration with other ministries • One way to approach this is through health in all policies • Another way would be health impact assessments • An intersectoral package for early adoption, even in LICs, has been recommended • There are a range of instruments that can be used for such approaches – finance, regulation, the built environment, education and information • Teach by issue, instrument, and platform and help students understand the “pathways” of analysis, action, and impact

5. Top 10 Causes of DALYs in 2015 Source: Data from Institute for Health Metrics and Evaluation (IHME). (2015). GBD heat map. Seattle, WA: IHME, University of Washington. Retrieved from https://vizhub.healthdata.org/gbd-compare/

6. Top 10 Risk Factors for DALYs in 2015 Source: Data from Institute for Health Metrics and Evaluation (IHME). (2015). GBD heat map. Seattle, WA: IHME, University of Washington. Retrieved from https://vizhub.healthdata.org/gbd-compare/

7. Determinants of Health Interventions Policies Governance Healthy Child Development Employment & Working conditions Physical Environment Individual Characteristics: Genetic Make-up Sex Age Social and Cultural Environment Access to Health Services Healthy Behaviors & Coping Skills Adapted from Skolnik, R. L. (2015). Global health 101. Burlington, MA: Jones & Bartlett Learning. p.21A

8. Impact of Top Environmental and Behavioral Risk Factors on Major Causes of Death Source: Watkins, D. A., Nugent, R., Saxenian, H. Yamey, G., Danforth, K., González-Pier, E., Mock, C. N., Prabhat, J., Alwan, A., Jamison, D. T. (in press). Intersectoral policy priorities for health. In D. T. Jamison, H. Gelband, S. Horton, P. Jha, R. Laxminaryan, R. Nugent, & C. N. Mock (Eds.), Disease Control Priorities (3rd ed.), Volume 9, Disease Control Priorities: Improving Health and Reducing Poverty. Washington, DC: World Bank.

9. Categories of Risk Factors • Intrinsic risk factors: cannot be modified but have an important relationship with well-being (examples: age, sex, genetic make-up) • Diseases as risk factors for other diseases: for example, diabetes is a risk factor for cardiovascular disease • Behavioral and environmental risk factors: includes diet, physical activity, tobacco smoking, air pollution, unsafe sanitation

10. Addressing Major Risk Factors for Death and DALYs • Intrinsic risk factors: almost always fall under purview of health sector • Diseases as risk factors for other diseases: often under purview of health sector, but the “risk factor disease” may be addressed via action outside the health sector (example: promoting girls education to reduce unsafe sex, to prevent HPV infection, which prevents cervical cancer) • Social and behavioral risk factors: can frequently be addressed by agencies outside the health sector (example: taxes on tobacco to reduce smoking)

11. “Health in All Policies” Approach • All ministries account for the health implications of their policies, plans, and programs • May not be feasible in low-income countries • If unrealistic, countries can selectively address high-impact health issues that require an intersectoral approach (e.g., tobacco)

12. Examples of the “Health in All Policies” Approach • Uganda: intersectoral committees to deal with the health of internally displaced people during conflict • India:intersectoral program to prevent infection of commercial sex workers with HIV through literacy and cultural programs, training in political advocacy, and microcredit schemes • Ecuador: intersectoral health council from ministries of health and education to address maternal mortality, child mortality, and illiteracy Source: Public Health Agency of Canada and World Health Organization. (2008). Health equity through intersectoral action: An analysis of 18 country case studies. Retrieved from http://www.who.int/social_determinants/resources/health_equity_isa_2008_en.pdf

13. Health Impact Assessments World Health Organization definition: “A combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.” World Health Organization. (n.d.b). Health impact assessment (HIA): Definitions of HIA. Retrieved from http://www.who.int/hia/about/defin/en/

14. Health Impact Assessments • Bring together and take account of the views of a wide range of stakeholders. • Take a broad perspective, looking at social, economic, and environmental issues, among other factors. • Examine whose health is likely to be affected by the investment that is being assessed. • Provide policy makers with data-driven recommendations about how to minimize the adverse effects of the proposed investment and maximize its health gains.

15. Putting Together an Intersectoral Policy Package (1/2) Source: Watkins, D. A., Nugent, R., Saxenian, H. Yamey, G., Danforth, K., González-Pier, E., Mock, C. N., Prabhat, J., Alwan, A., Jamison, D. T. (in press). Intersectoral policy priorities for health. In D. T. Jamison, H. Gelband, S. Horton, P. Jha, R. Laxminaryan, R. Nugent, & C. N. Mock (Eds.), Disease Control Priorities (3rd ed.), Volume 9, Disease Control Priorities: Improving Health and Reducing Poverty. Washington, DC: World Bank.

16. Putting Together an Intersectoral Policy Package (2/2) Source: Watkins, D. A., Nugent, R., Saxenian, H. Yamey, G., Danforth, K., González-Pier, E., Mock, C. N., Prabhat, J., Alwan, A., Jamison, D. T. (in press). Intersectoral policy priorities for health. In D. T. Jamison, H. Gelband, S. Horton, P. Jha, R. Laxminaryan, R. Nugent, & C. N. Mock (Eds.), Disease Control Priorities (3rd ed.), Volume 9, Disease Control Priorities: Improving Health and Reducing Poverty. Washington, DC: World Bank.

17. Teaching Intersectoral Approaches • By type of problem – such as undernutrition, unsafe water, air pollution, auto accidents • By the agency that needs to intervene – such as agriculture, civil works, education, finance • By the type of policy instrument – the built environment, education and information, fiscal and regulatory approaches • Pathways – students also need to understand the pathways by which different instruments “work” • Cases and examples can illustrate the issues and engage critical thinking about them

18. Questions?

19. Intersectoral Approaches to Enabling Better Health Bonus chapter – free bundle with Global Health 101, 3e Request complimentary review copies at go.jblearning.com/Skolnik Global Health 101, 3e review copies available atgo.jblearning.com/Skolnik3

20. Thank you for participating! Sophie Teague, Senior Marketing Manager Public Health & Health Administration steague@jblearning.com Richard Skolnik, MPA reston.richard@gmail.com Recorded webinar will be posted on the LinkedIn Public Health Faculty Lounge: http://go.jblearning.com/PHLinkedIn