This is pdf document of HSMN of UNIT 2

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Health Care System and
Strategies UNIT 4 INTER-SECTORALCOORDINATION
IN HEALTH CARE
Structure
4.1 Introduction
4.2 Coordination - Meaning and Related Concepts
4.3 Intra and Inter-sectoral Coordination (ISC)
4.4 Guiding Principles for Inter-sectoral Coordination
4.5 Areas of Inter-sectoral Coordination in Health
4.6 Coordination Mechanism and Benefits of ISC
4.7 Requisites for Effective Inter-sectoral Coordination
4.8. Let Us Sum Up
4.9 References and Selected Readings
4.10 Check Your Progress: Possible Answers
4.1 INTRODUCTION
Health is intrinsically related to development. However, the inter-linkages between
health and development were brought to the limelight at theAlma -Ata conference
on Primary Health Care (PHC) in 1978. TheAlmaAta conference not only gave
a new impetus to the inter-linkages between health and development, but also
restated the fact that ‘Health forAll’could not be achieved without inter-sectoral
co-ordination. This restatement gave a new direction not only to those involved
in promoting health but also to those participating in the process of community
development.
After going through this unit, the student should be able to
• explain the concept of inter-sectoral coordination (ISC) and its relevance to
the health of the people.
• analyse the interrelated departments directly or indirectly contributing to
the health.
• describe the mechanism of coordination within and outside the health sector.
• manage ISC effectively for health promotion and increased community
participation.
4.2 COORDINATION - MEANING AND RELATED
CONCEPTS
We might know that coordination is more closely related to collaboration and
convergence. The concept of coordination and others related concepts such as
cooperation, collaboration, and convergences are discussed below.
••••• Coordination means integration, synchronization or orderly patterning of
group efforts towards the accomplishment of common goals. Coordination
implies that all governmental and non-governmental agencies understand

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Inter-sectoral Coordination
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each other’s roles, speak the same language, avoid overlap and add value to
each other’s work. Coordination can be differentiated from ‘cooperation’
and ‘collaboration’ in a number of ways. The ultimate aim of coordination
is the convergence of health care services in the community. There can be
two types of coordination such as coordination within the department called
intra-sectoral, and between the departments called inter-sectoral coordination.
••••• Cooperation implies collective effort put in by a group willingly or
voluntarily for accomplishing some task. The effort does not have any
directional framework. It depends on people’s willingness to help each other.
••••• Collaboration refers to sharing similar responsibility by a group of people
or agencies based on agreements to carry out a project or programme.
Coordination, as distinguished from cooperation and collaboration, is more
participative, implies commitment, economizes effort, improves quality of
work, avoid duplication and wastage, and optimizes output.
••••• Convergence is a process that facilitates different functionaries and
community to work together for efficient service delivery. Convergence leads
to time saving, helps in building rapport with others, reduces workload, and
increases efficiency. Involvement and participation of a community is a
necessary pre-requisite for convergence.
4.3 INTRA AND INTER SECTORAL
COORDINATION
4.3.1 Intra-sectoral Coordination
The vertical health care system has been criticized for several reasons, one of
them is lack of coordination. The health sector with intra-sectoral coordination
has to coordinate with the family welfare, Ayurvedic, Unani, Sidha, homeopathy
(AYUSH) and nursing. It will be difficult on the part of health department to
achieve the Health ForAll without the intra-sectoral coordination. Under NRHM,
it has been realized that unless all the systems of health care are integrated and
delivered from single window, the outcome of NRHM will not be optimum. The
Health Department at the district level implements a number of programmes
such as malaria, leprosy, family welfare, RCH, etc.At the middle level a number
of officials are implementing them, and a District Health Officer coordinates
these programmes. Frequent meetings, sharing of experiences and success stories,
etc., are part of intra-sectoral coordination. The programmes those are needed to
be coordinated are immunization, RCH, nutrition, malaria, filarial, kalaazar
control, control of diarrhoeal diseases, home visits, and follow-up of family
planning acceptors, TB, etc. Besides, other programme implementation related
activities such as maintenance of health records, programme planning, monitoring,
evaluation and implementation strategies are also needed to be coordinated.
Conceptually, it is ideal, but in reality, ISC cannot be visualized only in terms of
physical presence of officials from different departments. They remain guided
mostly by their departmental identity. Therefore, ISC need to be understood in
terms of willingness (or, commitment) to change their departmental identity and
acquire a new collaborative identity. As a member of ISC they are supposed to
adjust into new roles, which is a great challenge because this requires handling
of different types of conflicts. Therefore to make ISC a success there is a

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Health Care System and
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tremendous need to create situation of understanding, coordination and
cooperation. An figure of intra-sectoral coordination is given in below.
Figure 1: Intra-sectoral Corrdination
4.3.2 Inter-Sectoral Coordination
TheAlma-Ata Declaration suggests a multi sectoral approach as one of the basic
principles underlying primary health care. The approach is based on the
assumption that health is intrinsically linked with other development issues in a
synergic manner. Some of the departments for inter-sectoral coordination are
Women and Child Development, Department of Education, Rural Development,
Rural Water Supply and Sanitation, Panchayati Raj Institutes, NGOs, the
Department ofAgriculture, the Department of Social and Tribal Welfare, and the
Department of Forest. The changes in other sectors affect health and similarly
health affects the development in other sectors also. Therefore, a better
understanding of the relationship between health and other development sectors
is needed for best results. As a matter of structural reality, development
programmes are being implemented by various ministries without successful
coordination at the level of planning. So much so even officials are not fully
aware of it. All development programmes needs to achieve some tangible
indicators related to the quality of life of the people. The success of development
should be viewed from the angle of those tangible indicators. This approach
would automatically bring all development agencies at one platform and this
would strengthen the concept of inter-sectoral coordination. There is a need to
develop a capacity development strategy in an integrated manner. Officials of
entire departments should have knowledge and understanding of the schemes,
which are interrelated. For example, the concept of good hygiene is linked to the
toilet facilities and water. The health department cannot promote the culture of
good hygiene without full support from departments that look after schemes
related to rural/urban toilet and water supply and, therefore, with the public health
department. Similarly, there could be several other examples. The statistics of
birth and death, early marriage, early pregnancy are vital for achieving the
desirable health indices. Without the support of the education and other like
departments directly addressing issues of birth and death registration, and child
marriage practices is impossible.The concept of ISC demands working in synergy.
Family
Welfare
AyushHealth
Homeopath
Nursing

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Inter-sectoral Coordination
in Health Care
Figure-2 gives an idea of the inter-relationship between some sectors in order to
deliver better health.
Figure 2: Inter-Sectoral Coordination
4.4 GUIDING PRINCIPLES FOR INTER-
SECTORAL COORDINATION
Within the health sector, a number of programmes are being implemented. Most
times, these programmes pursue their objectives in a vertical manner, losing
sight of the ultimate goal of primary health care. Before we begin to understand
the inter-linkages between health and other sectors, we must know some of the
guiding principles, which are important to the understanding of inter-sectoral
co-ordination. These principles are (i) development is basic to health, (ii) equity
in health and (iii) enhancing economic capacity of the poor people. These three
principles are not independent of each other and therefore they form the guiding
principle of Inter-Sectoral Coordination (ISC). A brief description of these
principles follows.
i) Development is basic to health: Health is closely related to development.
Health influences development and also influenced by development.
According to social scientists, improving the state of health contributes to
economic development, labour productivity and growth. There is strong
relationship between economic development and health, economic
development trends to improve health status, while better health contributes
to economic development.
ii) Equity: The most common understanding of equity, in terms of health, is
that “every man, woman and child, no matter where he or she lives, has the
right to enjoy good health and deserves to have access to health care services”.
This definition, then, implies the following. First, there must be enough
health care services - availability. Second, whatever is available must be
accessible to the poor, forgotten, and the marginalised.
Women/Child
Welfare
Education
Food/Civil
Supplies
AgriculturePublic HealthRural Development
Animal Husbandry Health

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Health Care System and
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iv) Promoting Economic Capacity of the Poor People: The economy “status
plays an important role in determining the health status of the people. It not
only enables the people to undertake preventive and curative health care
measures, but also promotes sustainability of their health status. Many
countries have initiated community specific strategies, and programmes to
improve economic capacity of the poor. Some of the key strategies are: (i)
asset creation and development, (ii) capital formation, (iii) employment
opportunities in the private or public sector, and (iv) access to market avenues.
I this section you read the meaning of coordination and related concepts, intra
and inter sectoral coordination, as well as the guiding principles of for
coordination, now attempt the questions given below and check your progress.
Check Your Progress 1
Note: a) Write your answer in about 50 words.
b) Check your answer with possible answers given at the end of the unit.
1) Discuss the need for coordination in the delivery of primary health care.
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2) List three major constraints in the way of effective coordination.
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4.5 AREAS OF INTER-SECTORAL
COORDINATION IN HEALTH
Areas of great concern for inter-sectoral coordination in health include promotion
of nutrition, supply of safe water, excreta disposal and refuse disposal, waste
water disposal, maternal and child health, family welfare, immunization against
major infectious diseases, prevention and control of locally endemic diseases,
health education on prevailing health problems. The inter-sectoral coordination
of health sector with other sectors for the promotion of the above mentioned
aspects are discussed below.
i) Promotion of Nutrition: the Health Department organises activities related
to educating pregnant and lactating mothers regarding quantity and quality
of food, supplementary nutrition, nutritional care of child, educating
adolescent girls and boys regarding health, food habits, food hygiene,

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Inter-sectoral Coordination
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balanced diet, malnutrition among children, food for geriatrics, adulteration
of food and subsequent diseases, role of kitchen garden, mid-day meals in
schools; organising nutrition education and preventing problems of
malnutrition and anaemia in the community. The activities of the other
departments where coordination can provide better result are listed below:
Agriculture Promote growing of cereals, pulses, oil seeds,
vegetables and local fruits to change eating habits and
their distribution through fair price shops or
cooperatives.
Education Organise sessions on food, food hygiene, nutrition and
preparation of balanced diet and special diet
supplements.
Social Welfare, Organise orientation programme for women on
Women and Child nutritional supplement and also monitor children
Development growth. To utilize services of primary health centre
for protecting children 0-6 years from communicable
diseases and mothers for check-up in the Integrated
Child Development Services Scheme (ICDS).
Panchayati Raj Encourage and support to prepare kitchen garden and
reward best garden and organise healthy mother and
baby competition and help health personnel for
organisation of immunisation and health camp.
Animal Husbandry Help in monitoring health of milch animals, such as
cows, goats, buffalos, etc., and poultry farming, fish
tanks and sale of milk, eggs, and fish through village
cooperatives.
Cooperative To store agricultural food and home grown vegetables
and sale through village cooperatives.
Banks Financial assistance to villages for promotion of dairy,
fishery and poultry at the village level.
ii) Supply of Safe Water: Health departments need to coordinate with the public
health department for supply of safe drinking water. The public health
department is involved in site selection and surveys for water sources; water
analysis; and educating communities on how to get safe water. The other
departments can coordinate with the public health and health department in
ways described below.
Agriculture Coordinating and cooperating with public health and
health sector in identifying water sources and
utilization of water for drinking purposes.
Education School health education on safe water and its
importance.
Panchayati Raj Providing finance for maintenance of water sources.
Social Welfare/ Organizing women’s groups on maintenance of water
Women and Child sources and use of safe water.
Development

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Health Care System and
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iii) Excreta and Refuse Disposal: Health and Public Health Department
conducts education at the household level for use of sanitary latrine and safe
garbage disposal. The activities of other departments can be coordinated in
ways described below.
Agriculture Organizing educational programme on proper
composting.
Cooperative Evolving cooperative community composting.
Education Conducting school health education on proper disposal
of excreta and composting. Construction of school
toilets.
Panchayati Raj Providing financial support for sanitary community
latrine and community composting and organising
education on proper collection and disposal of excreta.
Rural Development Manufacturing latrine sets; manufacturing equipment
for latrine construction and composting.
Social Welfare/ Organising women’s group on safe excreta disposal
Women and Child and composting.
Development
iv) Waste Water Disposal: Health and Public Health Department organises
health education camps on methods of safe disposal of waste water and its
advantages to the community. Other sectors/departments need to coordinate
with the health department in activities with a similar objective.
Education Educating the children on safe waste water disposal
and its advantages; adult education on safe disposal
methods and its advantages.
Agriculture Providing drainage for household kitchen garden and
community kitchen garden.
Cooperative Financing preparation of kitchen garden; financing for
soakage pit construction.
Panchayati Raj Providing finance for community kitchen garden and
soakage pits construction.
Rural Development Encourage and provide fund for manufacturing
Social Welfare/ equipment for laying kitchen gardens, and excavation
Women and Child of soak pit and soak wells.
Development Educating the women on maintenance of kitchen
garden and its advantages and fruitful use of waste
water.
v) Maternal and Child Health: Health Department is responsible for health
education on ante-natal, natal, and post-natal care; infant and child care; and
other related maternal and child health care services. The similar activities
of other departments/ sectors can be integrated.

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Inter-sectoral Coordination
in Health CareCooperatives Organizing cooperative insurance scheme for MCH
care.
Education Health education to school going children and care of
personal hygiene.
Panchayati Raj Provision of sub-centre buildings, crèche buildings and
Social Welfare/ support for MCH Programme.
Women and Child
Development Organising and educating the women on maternal and
child care.
vi) Family Health Care Education: The Health and FamilyWelfare Department
conducts health and family welfare education through various communication
methods at the grassroots. The similar activities organised by other
departments/sectors are described below.
Education Organising population education in schools and adult
education centres. Integrating population education in
the school curricula.
Panchayati Raj Provide help in the organisation of camps, motivation
and community involvement in the family health care
education.
Social Welfare/ Organising and conducting educational sessions for
Women and Child women at the grassroots level. Particularly women
Development belonging to weaker and socio-economically backward
sections of society.
vii) Immunization Against Major Infectious Diseases: Health Department
organizes and conducts educational programmes and provide service facilities
on immunization through the health centre personnel at various levels. The
related activities of other departments follow.
Education - Health education on various immunizations like
cholera, typhoid,TB, tetanus etc. Helping in organizing
school immunization programme. One of the examples
is school teachers providing support to health
department in the smooth conduction of Pulse Polio
Programme.
Panchayati Raj Propagation of health message through posters and
group discussions.
Social welfare, Education of mothers through Mahila Mandals,
Women and Child Anganwadis and women’s groups.
Development
viii) Prevention and Control of Locally Endemic Diseases: Health
Department organises education on diagnosis, treatment, and follow-up of
cases of TB, leprosy, malaria, scabies, etc. The related activities of other
departments follow.

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Health Care System and
Strategies Animal husbandry Immunization of cattle and domestic animals against
rabies, etc.
Education Education about early diagnosis and prevention ofTB,
leprosy, malaria, scabies, etc. through population
education and provide help in organising health camps.
Panchayati Raj Propagation of health messages through wall paintings,
posters and folk media.
Social Welfare/ Education on prevention of communicable diseases,
Women and Child through self help groups, mothers committees, etc.
Development
ix) Improvement of overall Environment in Primary Health Centre
premises: This includes plantation, gardening, water supply, sanitation. The
other department can provide help to improve the health care centre premises.
Forest Provision of trees and plants
Public Health Provision of waste and sanitation facility
Panchayati Raj Over all support including finance
NGOs Community education and community mobilization
Community Based Community education and community mobilization
Organisations
4.6 COORDINATION MECHANISM AND
BENEFITS OF ISC
In order to coordinate the different units, the health sector needs to evolve various
mechanisms of coordination at the intra and inter organization level. These are
i) listing out the programmes which need joint efforts
ii) identifying the areas where coordination is required
iii) knowing the categories of health personnel whose activities should be
integrated
iv) locating the levels of health systems where joint efforts are needed
v) forming coordination committee of members of district health team which
includes all the middle level supervisors and specialised functionaries
working at district level and
vi) forming operations teams at field level
vii) list different sectors, such as social welfare, women and child development,
public health, rural development, municipalities, and municipal
corporations, and the heads of those sectoral units which are directly or
indirectly related with health and family welfare programmes
viii) identify the non-governmental and voluntary health organisations, which
are working in the area of health and family welfare

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ix) constitute a coordination committee with the representatives from district,
block, and village levels
x) formulate specific task-forces
xi) jointly decide the objectives and areas for coordination to achieve desired
goals
xii) decide the role and responsibility of each department and mechanism of
reporting and feedback sharing
xiii) develop a plan of action that focuses on independent tasks, joint tasks,
sharing of resources, and field work in teams.
4.6.1 Benefits of Inter-sectoral Coordination
The benefits expected from inter-sectoral co-ordination are
i) achievement of goals which cannot be achieved alone,
ii) increases the chance that those policy alternatives are chosen which are most
likely to result in the highest overall welfare gains
iii) helps prevent overall welfare losses because of policies that entail positive
welfare effects for individual actors, but disadvantageous from an overall
point of view
iv) provides legitimacy and acceptance to public policy.
To sum up, inter-sectoral co-ordination is likely to lead to more effective public
policies due to enhanced governance knowledge, mutual learning, reduced risk
of deadlocks in decision making, avoidance of unintended side effects, and the
prevention of implementation resistance.
4.7 REQUISITES FOR EFFECTIVE INTER-
SECTORAL COORDINATION
Some of the pre-requisites for the effective inter-sectoral coordination are listed
below.
i) Establishing an overall inter-sectoral strategy- this step is added for the
sake of completeness, but is unlikely to be attainable in practice.
ii) Establishing commonly agreed or binding priorities- inter-sectoral
agreement to common priorities and/or central agencies lays down the main
lines of policy and establishes cross-sector priorities.
iii) Defining common limits by setting parameters for sectoral activities- a
central organization of an inter-sectoral decision-making body may play a
more active role by constraining the admissible range of sectoral activity.
The parameters define what sectoral actors must not do, rather than
prescribing what they should do.
iv) Arbitration of inter-sectoral differences- where inter-sectoral differences
cannot be resolved by the horizontal co-ordination processes defined in steps
two to four, a central mechanism of an ex ante commonly agreed procedure
for arbitration is applied (e.g., state hierarchy, voting).

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Health Care System and
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v) Avoiding policy divergences among sectors and seeking consensus-
beyond negative co-ordination, to find out differences and prevent mutual
negative effects, the actors/organizations should work together by forming
joint committees and project teams, because they recognize their
interdependence and their mutual interest in resolving policy differences.
vi) Consultation with others- as a two way process, sectors/actors need to
inform others about what they are doing; they consult others in the process
of formulating their own policies, or positions.
vii) Information exchange among sectors- sectors/actors keep each other up
to date about recent issues and problems and how they propose to act in their
own areas and also in coordination of one another. Reliable and accepted
channels of regular communication must exist.
Steps required for Effective Inter-sectoral Coordination (ISC)
Effective coordination depends on leadership style and willingness to collaborate
with other sectors. It is essential to inform others about the health policies and
priorities. Some of the necessary actions required to be taken for ISC are listed
below.
a) Proper orientation of policies and programme of each developmental
department at all level.
b) Formation of joint coordination committee at each level i.e., village/block/
district.
c) Defining roles and responsibilities of participatory agencies and classifying
them to each other.
d) Participatory decision making.
e) Developing a formal system of interaction, discussion and debate.
f) Sharing of the problems faced in implementation of health programmes and
seeking cooperation from each partner.
g) Spelling out strategies and procedures.
h) Joint monitoring and evaluation.
i) Remedial measures in solving problems related to coordination/resource
mobilization.
In this section you read areas of ISC in health, cordination mechanism, benefits
of OSC and requisites for effective ISC, now attempt following questions and
check your progress.
Check Your Progress 2
Note: a) Write your answer in about 50 words.
b) Check your answer with possible answers given at the end of the unit.
1) Identify the areas of great concern for linkages with PHC.
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2) Detail the steps required for effective inter-sectoral coordination.
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4.8 LET US SUM UP
The goal of all the developmental activities is a comprehensive, overall socio-
economic development of the community in which other sectors contribute to
health and vice versa. The coordinated health care activities involve working
with people, people’s elected representatives (PRI), local groups, youth clubs,
mahila mandals, self-help groups, NGOs, etc. The ultimate aim of coordination
is convergence of health care services in the community. Convergence is a process
that facilitates different functionaries and community to work together for efficient
service delivery. Convergence leads to savings in time, helps build rapport with
others, reduces workload, and increases efficiency. The involvement and
participation of communities is a necessary pre-requisite for convergence. It has
certain advantages, as the process of working together and sharing ideas leads to
value addition; and the cumulative effect of each functionary’s work, when they
coordinate, becomes more than the sum total of their work altogether. Broadly,
there are two types of coordination; that is within a department, known as intra-
sectoral; and between departments, called inter-sectoral coordination. To
coordinate the different sectors and non-governmental organizations, there is a
need to create task-forces and committees of heads of different institutions and
organizations operating in a district. It is desirable to design and plan programmes
based on a multi-sectoral and convergence approach. Some experiments have
already being carried out in the country. They provide valuable insights into the
process of coordination. For example, Integrated Child Development Services
Scheme (ICDS), the biggest programme of child development in the country,
envisages the delivery of a package of services including health, nutrition, pre-
school education, and community participation in an integrated manner. The
inter-sectoral coordination would result in effective implementation of health
sector programme.
4.9 REFERECES AND SELECTED READINGS
W.H.O. (1986), Inter-sectoral Action for Health, Geneva.
N.I.H.F.W. (1981), Health for All, (Report of Working Groups), Government of
India, New Delhi.
Schaefer, M (1981), Inter-sectoral Coordination in Environmental Management,
W.H.O. Pub H. Papers 74, Geneva.
KhanA.M (2004), Panchayat in Health Sector, Social Change, December, 2004,
Vol.34, No.4: pp. 47-60.
IrwinA, Scali E (2007),Action on the Social Determinants of Health:AHistorical
Perspective, Global Public Health, 2(3): pp.235-256.

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OECD (1996), Globalisation: What Challenges and Opportunities for
Governments? Paris.
Scharpf, F.W. (1993), Coordination in Hierarchies and Networks. In Scharpf,
F.W. (ed.): Games in Hierarchies and Networks.Westview Press, Boulder. Pp.125-
166.
Arole, Raj & Mabelle Arole (1994), Jamkhed: Comprehensive Rural Health
Project, Macmillan.
Tarimo E and A. Greese (1990), Achieving Health for All by the Year 2000 AD,
WHO, Geneva.
Web sites: -
http://www.metla.fi/eu/cost/e19/hogl1.pdf
http://www.phac-aspc.gc.ca/publicat/2007/cro-sec/2kt-eng.php
4.10 CHECK YOUR PROGRESS: POSSIBLE
ANSWERS
Check Your Progress 1
1) Discuss the need for coordination in the delivery of primary health care.
Answer. Since the Alma Ata conference (1978), Primary Health Care has
given most important strategies for effective solution of health problems
and development. It also stressed the missing concern of inter-linkages among
various sectors related to health and restated the fact that ‘Health for All’
could not be achieved without inter-sectoral co-ordination. The scholars,
the policy makers and the development functionaries promoting an inter-
sectoral approach to health tend to consider seriously three major sectors
(agriculture, education and environment) that are crucial for health and
development.
2) List three major constraints in the way of effective coordination.
Answer. The major three constraints are: 1) perspective of health, 2)
knowledge, attitude and 3) practices and all the three need to be dealt under
different strategies.
Check Your Progress 2
1) Identify the areas of great concern for linkages with PHC.
Answer. Areas of great concern for PHC and inter-sectoral coordination
are: 1) Promotion of Nutrition, 2) Supply of Safe Water, 3) Excreta Disposal
and Refuse Disposal, 4)Waste Water disposal, 5) Maternal & Child Health,
6) Family Welfare, 7) Immunization against major Infectious Diseases, 8)
Prevention and Control of locally Endemic Diseases, 9) Health Education
on Prevailing Health Problems.
2) Detail the steps required for effective inter-sectoral coordination.
Answer. Effective coordination depends on leadership style and willingness
to collaborate with other sectors. Therefore, it is essential to make others
know the health policies and priorities. Some of the necessary pre-requisites
for ISC (mentioned in section 3.8)