Whole of government and whole of society approaches: call for further research to improve population health and health equity

On 9 April 2020, WHO Director-General Dr Tedros Adhanom Ghebreyesus stated, ‘this pandemic is much more than a health crisis. It requires a whole-of government and whole-of-society response’.¹ To address the ongoing pandemic, national, regional and global policymakers continue to call for whole of government (WoG) and whole of society (WoS) strategies.^{2 3} Countries’ responses to COVID-19 exemplify the relevance of WoG and WoS approaches, as a means to bringing together different actors to address complex challenges and achieve interrelated goals—essential in the Sustainable Development Goals (SDGs) era. Indeed, the indivisible nature of the SDGs presents an ideal opportunity to enhance multisectoral collaboration,⁴ but what do WoG and WoS approaches mean in theory and in practice? How widely shared is their understanding, and how are these concepts implemented? Which factors facilitate or hinder implementation? What do these approaches add to the existing discourses on multisectoral action for health? And how might researchers advance conceptual clarity and assess implementation? The purpose of this commentary is to provide insights as to how WoG and WoS approaches are understood and implemented, and to identify potential barriers and areas for further research.

WoG and WoS approaches to health: development and definitions

Health policy approaches and frameworks are contested and shaped by dominant political paradigms, actors and agendas.^{5 6} The idea that health is affected by policies beyond the health sector is not new.⁷ The 1978 Alma-Ata Declaration and ‘Health for All’ agenda established the principles of universal access, equity, participation and intersectoral action for health and acknowledged the importance of the social determinants of health (SDHs).^{5 7} Later, the 1986 Ottawa Charter for Health Promotion recognised a broader range of SDH and called for engaging non-state actors along with governments. It introduced the Healthy Public Policy approach calling for ‘an explicit concern for health and equity in all areas of policy and an accountability for health impact’.⁷ This concept evolved into the Health in All Policies (HiAP) approach, defined in the 2013 Helsinki Statement as ‘an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity’.^{8 9} There is now a growing body of literature on collaboration, governance and action across sectors to improve health. Despite efforts to define them more precisely, the qualifiers ‘intersectoral’, ‘multisectoral’ and ‘cross-sectoral’ are used interchangeably.

WoG is defined as an approach ‘in which public service agencies work across portfolio boundaries’ to develop integrated policies and programmes towards the achievement of shared or complementary, interdependent goals.¹⁰ WoS represents a broader approach, moving beyond public authorities and engaging ‘all relevant stakeholders, including individuals, families and communities, intergovernmental organizations, religious institutions, civil society, academia, the media, voluntary associations and […] the private sector and industry’.¹⁰ These terms are also used interchangeably without rigid demarcation, and it is contestable whether they truly have greater or differing specificity as compared with ‘multisectoral’, ‘intersectoral’ or ‘cross-sectoral’.

The common rationale for these approaches is twofold. First, there is the recognition that health is highly dependent on sectors beyond healthcare and is greatly influenced by the SDH. Second, to address the multidimensional and transdisciplinary challenges inherent to the SDH, there is the technical need to overcome departmentalism and siloed work, to increase policy coherence and effectiveness.^{9 10} The concept of intersectoral action has the longest history within the field of public health, but the terms WoG, WoS and multisectoral action have long been mentioned in public administration and have increasingly been applied to health under the banner of HiAP.

Meanings, equivocations, misapplications, barriers and missed opportunities

Despite a growing body of literature analysing HiAP efforts,^11–13 evidence focusing on approaches to health explicitly labelled as WoG or WoS remains mostly descriptive, with limited analytical and evaluation insights.^{14 15} Yet, the literature assessing progress and challenges of HiAP is still relevant when considering barriers to WoG or WoS. In this regard, a 2019 Global Status Report on Health in All Policies reviews efforts in 41 countries.¹² Among key findings are (1) the lack of governance mechanisms and structures for successful implementation, (2) the importance of dedicated resources for HiAP activities, (3) the recognition that there is no one-size-fits-all HiAP approach, and (4) the acknowledgement that health policymakers sometimes lack negotiation and diplomacy skills to collaborate with non-health sectors.¹²

While some efforts to evaluate HiAP and multisectoral collaboration to health in low-income and middle-income countries (LMICs) have been made (including by the Global Network for Health in All Policies and WHO),^13–15 knowledge gaps remain. For instance, implementation mechanisms for multisectoral collaboration are underinvestigated, and available implementation research mostly consists of case studies which do not allow for generalisation. Other limitations are difficulties in measuring outcomes and impact of multisectoral efforts and the limited understanding of the role of power dynamics.^{14 15}

The literature that does exist on explicitly labelled WoG and WoS approaches to health is largely dominated by a focus on high-income countries (HICs) and upper-income and middle-income countries. These strategies are frequently implemented in British Commonwealth countries (initially as part of the broader ‘new public management’ movement) and Northern European countries.^{16 17} There has also been some adoption in Asian countries, such as Indonesia and South Korea, and in the USA.¹⁷ Several HICs started implementing WoG strategies in the 1990s. This is the case of the ‘Joined-Up-Government’ in the UK, WoG task-forces in Australia and Canadian efforts.¹⁷ Most of these were primarily focused on efficiency gains, while contemporary efforts, such as Scotland’s whole system approach to public health, are also driven by the prospect of improved outcomes, sustainability and equity.¹⁸

There are limited studies on WoG and WoS approaches in LMICs. Evidence on WoG strategies in Latin America suggests that health policy has played a marginal role.¹⁹ Available (though perhaps outdated) literature from Africa shows that the adoption of WoG and WoS strategies has been restricted to specific priority areas, especially communicable diseases, malnutrition and mental health.²⁰ Reasons for the limited implementation of these approaches in LMICs include lack of capacities and skills essential to cross-sectoral collaboration (eg, negotiation, partnerships and communication); lack of incentives to work across sectors; resources mostly allocated to vertical programmes; administrative challenges such as limited institutional infrastructure (often highly hierarchical); lack of strong accountability systems; political instability and weak leadership.^{4 19–21}

WoG and WoS approaches to health (including when framed under the umbrella of OneHealth²²) are intended to address complex health challenges, such as non-communicable diseases,^{23 24} epidemics and pandemics.^{25 26} Other domains of application, including urban health,²⁷ mental health,²⁸ sexually transmitted diseases, and maternal and child health, are also covered in the literature and in a number of policy documents.^29–31 While the theoretical understanding of WoG and WoS approaches is generally consistent with WHO’s definitions, other terms like HiAP, intersectoral or multisectoral action may be used to refer to the same concepts.^{23 32–34} Moreover, WoG is sometimes conflated with WoS.^35–37

As with the literature on inter- or multisectoral action and HiAP, most WoG studies stress the importance of effective communication among actors and of a shared understanding on priorities and objectives.23 32 34 36 For example, Tak et al and Lencucha et al highlight the value of timely information sharing to improve decision-making processes and coordinated responses, and ensure situational awareness across all government agencies.^{32 33} Indeed, miscommunications resulting in different understandings of key concepts, diverging value systems, institutional agendas, and political ideologies, are major factors hindering implementation.23 32–34 36 Furthermore, Van Eyk et al, learning from HiAP efforts, emphasise understanding the goals of other sectors to ensure cobenefits.²³

Studies focusing specifically on WoS strategies show similar challenges and recommendations to the literature on WoG, and the broader literature on intersectoral and multisectoral action and HiAP. These include lack of coordination among stakeholders, confusion on roles and responsibilities, low levels of engagement from actors whose agendas are not aligned; lack of a common language for information sharing; and little recognition of health and human development as drivers of innovation and economic growth.^{26 38–40} WoS studies highlight the importance of tools and platforms for real-time data sharing and analysis, to optimise coordinated decision-making and action.^{26 38–40} While recognising the added value and benefits of involving public, private and civil society actors in a collaborative effort, how to do so remains a challenge, with many countries struggling to translate theory into practice.^38–40 For instance, ensuring that all relevant members of society are adequately represented and all voices are being equally heard can prove difficult.

The potential for further research

How might researchers advance conceptual clarity and assess implementation of WoG and WoS strategies? The overarching question is whether a specific research focus on WoG and WoS approaches to health adds anything to the existing discourse on intersectoral and multisectoral actions for health and HiAP.

The value of conducting further research on WoG and WoS lies in the currency of these terms outside the health sector, including at the executive level. The health sector often fails to recognise the value of knowledge produced outside its aegis. Therefore, a primary value of considering WoG and WoS approaches is to learn from experiences and literature whose concern is not specifically improving health outcomes. Additionally, WoG and WoS approaches might contribute to realising the vision of HiAP by overcoming implementation challenges. Thus, future research efforts on WoG and WoS should start by considering identified barriers to advance HiAP and intersectoral and multisectoral actions to health.^{12 41} To address these barriers, both policy and implementation research efforts will be required.

Enhancing conceptual clarity on WoG and WoS requires the establishment and consolidation of long-term learning, engaging both policymakers and researchers in jointly developing common language. The application of systems-thinking theory and methods is fundamental in this process. Conducting substantial implementation research and evaluation of countries’ experiences with WoG and WoS strategies to health is also essential to collect evidence, compare and contrast, and draw lessons. Complex health policies and interventions are usefully assessed by realist evaluation that aims to elucidate ‘what works, for whom, under what circumstances, and how’,^{4 42} and which necessarily employs a combination of qualitative and quantitative methods over the mid-term to long term.

Finally, in practice advancing WoG and WoS strategies requires institutional and administrative changes, as well as knowledge and capacity building. This all needs to be undertaken closely bridging and linking to existing and future efforts in the broader areas of intersectoral and multisectoral actions for health and HiAP, as it is imperative not to create siloed research efforts.

The current COVID-19 crisis showcases that no single entity has the resources and capacity to effectively address a global pandemic. This experience provides a timely stimulus for research that helps to accelerate efforts to work across societies to solve complex health problems. Further research on WoG and WoS approaches can make an important contribution to addressing issues like COVID-19 that urge the adoption of ‘a whole-of-society model for the whole-of-the world’.³⁸

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