Welcome back. Today, we're going to speak about Intersectoral Approaches to Enabling Better Health. By the time you finish this session, you should be able to take a broad view of the factors that determine health and the range of measures across agencies that are needed to ensure better health, articulate the value of health impact assessments and how they are conducted, speak about a "health in all" perspective for government policymaking, and note the most important policy measures that countries can take to address health through intersectoral approaches. Let me begin as I so often like to do with three vignettes. Juan is a four-year-old boy in Guatemala. His family is poor. They were uneducated, and they're from a minority ethnic group. Juan's family also lacks access to safe water and sanitation, and he frequently gets infections, including lots of bouts of diarrheal disease. Juan is stunted. He is much too short for his age. It's also likely that Juan's full cognitive potential will never be realized because he's been undernourished for so long. So, let's ask, why is Juan so malnourished? Is it because his family lacks access to safe water and sanitation, he gets diarrheal disease, and can't sustain his nutrition? Is it because they're poor and he doesn't get enough nutrition in the first place? Is it because his family is poorly educated and therefore, maybe lacking in the knowledge needed to either get good employment or to do as much as they can to help ensure the good health of their family? And when we think about those, what's the likelihood that the Ministry of Health alone could take the measures needed to ensure that children like Juan are well-nourished, they're healthy, and they thrive? Shahnaz is a 24-year-old woman in Pakistan. She's been sick for some time with night sweats, coughing, and even coughs up blood from time to time. She fears that she has tuberculosis. However, she will not seek treatment for her illness because she fears the stigma and discrimination that would come to her if people knew that she had TB and the possibility that she might even be asked to leave the house of her in-laws in which she's living. The crowded conditions in which she lives are an important risk factor for contracting tuberculosis. And in addition, the gender norms in Pakistan clearly mitigate against through seeking treatment. So, as we did for Juan, let's ask ourselves, why did she get TB? Is it because the family is poor and lives in crowded circumstances? Is it because they have lots of people in the house because they haven't been able to make or haven't chosen to make choices about a family size that might be easier for them to handle? Is it because she didn't get much education because she's a girl? And let's ask again, what's the possibility that in at least the medium or longer term, the Ministry of Health alone could address issues of tuberculosis control in this kind of a social and economic setting? And finally, let's talk about Josef. Josef smokes tobacco. He's aware of the health risks of smoking. However, he smoked for many years. He smokes a lot. He doesn't feel like quitting, and he doubts, in any case, that he could quit. He just can't. He feels like he can't quit. Josef has received information from the Health Ministry, and from family, and others about the risks of smoking, which he's fully aware. He's been counseled on quitting. He's received nicotine replacement patches, smoking cessation patches, but he just can't quit. Now, what's the possibility that the Ministry of Health alone can take measures to help people like Josef reduce their tobacco consumption and to prevent young people from taking up cigarette smoking in the future when we know, for example, that the single most important policy measure to reduce tobacco consumption and the uptake of tobacco will be taxes, which are in the purview of the Ministry of Finance and really not in the Ministry of Health? So, if we're going to think, for example, about the need for moving beyond the Ministry of Health, let's start by looking again at why is it that people get sick, disabled, or die especially of preventable causes or prematurely, what the risk factors are for those causes of illness, disability, and death. And then, let's look at the extent to which some of these most important risk factors and determinants are amenable to being addressed by the Ministry of Health compared to the need for intersectoral approaches, and we'll look at what some of those approaches might be, and how they might be put into place. So, let's remind ourselves that the most important risk determinants of health, generally, are thought about as individual characteristics like genetic makeup, sex, and age, a range of social behavior and environmental factors like healthy child development, the physical environment in which you live, behavior and coping skills, social and cultural factors, employment and working conditions, and access to health services. And we also know, for example, that there are a range of other societal issues that really make a big difference in terms of their importance to enabling or disabling people's health. And this includes, for example, the manner of governance in the country, whether or not the government puts a high priority on the health, and well-being, and education of their people, the policies that they manifest in a range of domains that affect health, and the kinds of interventions that they support, whether or not they're high priority interventions, whether or not they're well implemented, for example, and whether or not they focus on the people who most need to be better unable to be all that they can be in terms of their overall well-being and their health. And we also know that beyond what's represented in this graphic, that the social determinants of health are also very, very important. And the World Health Organization defines these as the conditions in which people are born, they grow, they work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. We know there are certain determinants that are really quite close to him, very directly related to our health. We know there are others that are more indirect. And we also know there's a whole range of what they call the social determinants of health that are really important to whether or not people are healthy. Let's look now at the risk factors for disability-adjusted life-years by country income group for 2015. And here, we're looking at the World Bank country income groups, from low income, lower middle, upper middle, and high. And we see at least by looking at the extremes that when it comes to the most direct risk factors as examined and articulated in the studies published by the Institute of Health Metrics and Evaluation, we know that for the lowest income countries, many of them have to do with environmental factors like access to safe water and safe sanitation, like household air pollution, and the manner in which people cook indoors in many countries, and behavioral factors such as suboptimal breastfeeding, which is enormously important risk for child well-being and their ability to thrive. When we look at the high income countries, we see that the list includes overwhelmingly, what we would call, social and behavioral risk factors. And this is very important because when we're thinking about interventions to enable a better health, and whether or not the Ministry of Health can lead and take most of them, or the extent to which they have to go beyond the Ministry of Health, it's important to note that the extent to which, what we call, environmental and behavioral risk factors are really important especially because this so often require action and intervention beyond the Ministry of Health itself. So, here, we see when it comes to what they used to call group one, group two, and group three diseases, the exceptional importance of these environmental and behavioral risk factors, which are related to about 30 percent of the communicable, maternal, perinatal, and nutritional conditions, they say around 25 percent of non-communicable diseases, and around 20 percent of injuries. And you can see, for example, here, the types of specific risk factors that are so important in determining. So important to these causes of illness, disability and death. Now, it will be helpful as always if when we think about risk factors as well as many other matters to categorize them. And one way of doing so would be to think about these intrinsic risk factors, like the center circle and the determinants chart that you saw, and ask ourselves for these categories of risk factors. What is the extent to which they're amenable to being addressed through the Ministry of Health? Or the extent to which they depend on actors beyond the ministry? When we think about intrinsic risk factors; age, sex and genetic make-up, here we generally understand that, A, there's not much that can be done to modify them. But B, if there are modifications, they often are highly technical or are related to genetics and will almost always fall in the purview of the Ministry of Health or certain scientific bodies. When we think about the health and well-being and the development of young children, we know that that depends on a wide range of matters. For example, is the adolescent mother healthy and well-nourished? Does she have access to skilled birth attendants? Does she have access to emergency obstetric care? Is the child breast fed in an optimal way? Can the family afford and provide and be knowledgeable about the kinds of food the child needs to thrive both as a complement to breast feeding and then afterwards? Is the family educated enough? For example, to ensure that they have the knowledge to care well for themselves and their family and to gain well-paying employment that can help support their lives. It doesn't take much when we think about the factors that go into whether or not a child develops well in utero, whether a child is born well, whether or not a child thrives after that. It doesn't take much to understand. The Ministry of Health can dramatically influence some of the factors that are concerned. But it's also quite obvious that other ministries must also be involved. Education is in the purview of the Education Ministry. Agricultural prices and agricultural markets will often fall somewhere between finance, commerce and agriculture, for example. And there are a number of other matters, like whether or not there are smoking in the family, that will depend much more on interventions from the Ministry of Finance and/or law enforcement agencies. So when we think about developmental risk factors and the well-being of young children, it's quite clear that families, communities, nations and the globe as a whole will have to go beyond just the Ministry of Health. There's also a category called diseases as risk factors for other diseases. It might sound a little complicated. It's not as complicated as it might seem. But we know, for example, that diabetes is a risk factor for cardiovascular disease. So let's ask ourselves if one wants to avoid cardiovascular disease, it's important to reduce the burden of diabetes and what's the extent to which the Ministry of Health alone can do that? They can diagnose people with diabetes. They can treat people with diabetes. They can encourage healthy eating behaviors. They can encourage and promote better exercise, more physical activity. And yet we also know that this too has something to do with the kinds of food that people eat, what's available to them, regulations on the content of different foods and the amount of sugar, for example, that they can have in them, et cetera. And we know that these are matters that go beyond the Ministry of Health. When we think, for example, of let's talk about HPV infection, infection with human papillomavirus which is related to unsafe sex and also so closely related with cervical cancer. There are quite a range of reasons why people engage in unsafe sex. But some of them have to do with gender disparity and discrimination with the lack of economic power that might lead in some circumstances, for example, to transactional sex. The Ministry of Health can promote safe sex, it can have an important influence on the use of condoms when people engage in sexual activities. And yet, when one goes beyond that and looks at some of the structural reasons, why a young woman, for example, in some countries in Sub-Saharan Africa might engage in transactional sex, it's quite clear that this has a lot to do with gender norms, with economic opportunities for woman and the education that they have, all of which go beyond the ability of the Ministry of Health alone to influence. And finally, we know from the other chart that there's an important extent to which social, environmental and behavioral risk factors relate to the causes of death and disability. And here, three very important examples would be tobacco, where as I mentioned before, the single most important intervention is raising taxes. That's beyond the Ministry of Health. Safe water and sanitation. Here, generally, countries have ministries of works or ministries of infrastructure, and access to safe water and sanitation might be encouraged by the Ministry of Health, but it's the Ministry of Works that would generally carry out these efforts with the support of course of the Ministry of Finance. And outdoor air pollution is quite a complicated matter that might have to do with industrial licensing and permitting regulations on pollution and on anti-pollution devices. And if countries wish to reduce the burden of outdoor air pollution and the risk that it poses for ill health, then these countries will almost certainly have to move beyond the Ministry of Health and involve the Ministry of Energy, the Ministry of Industry, the Ministry of Commerce, the Ministry of Finance and sometimes even law enforcement. So it's quite clear that when we look at what it is that people get sick, disabled and die from? There's a very large range of important risk factors and determinants for which the Ministry of Health might be able to play an important role. But to really enable better health, it's going to be essential that countries take an intersectoral approach that goes beyond just the Ministry of Health. One way that countries can do this is called a Health in All or a Whole of Government approach. In this case, and there's a number of countries that come close to doing this pretty well. And the best examples are said to be Norway, New Zealand, United Kingdom, and Cuba. And in this case, for example, if I were the prime minister and I promise you no one is going to make me the prime minister of any country anytime soon, but if I were the prime minister and I were presiding over a cabinet meeting and we were talking about reducing outdoor air pollution, in a Whole of Government approach I would say to the ministers of commerce and the Minister of Industry and to the Minister of Finance, for example, and I would say, "Madam Minister, we take a Health in All approach or a Whole of Government approach to trying to enable the better health of our people. And therefore, what I'd like to do in the meeting today, is talk about the efforts we're going to make as a government as a whole to reduce air pollution and to enable the better health of our people. So let's talk about the contribution that the Ministry of Commerce, the Ministry of Industry, and the Ministry of Finance, and perhaps even law enforcement could make to ensuring over the next five to 10 years that we can really reduce outdoor air pollution, and create a much more healthier environment for our people." Now, one can easily imagine that in some low and low capacity countries that this Health in All or Whole of Government approach might not be so easy. But it's probably realistic that even in relatively poor countries that they can take a Health in All approach at least to specific topics, and certainly one of the best would be tobacco. Certainly, even the poor countries that have less government capacity, one can imagine the president or prime minister saying, "We can't do this for as many things as New Zealand, or Norway, or the U.K., but certainly when it comes to tobacco, there's very good evidence about what needs to be done. So let's talk today about what we're going to do about tax policy, access to sales of cigarettes and tobacco, and how we're going to enforce that even though we have to say for right now we can't take a Whole of Government approach to many more issues." And there are some good examples from a number of countries, including Uganda, India and Ecuador, where they took a kind of Health in All approach at least to certain very important topics as you can see here. Another way that countries can seek to address critical health issues across ministerial and agency lines is through what we call health impact assessments. And a health impact assessment, WHO defines a health impact assessment as a combination of procedures, methods, and tools by which a policy, program, or project might be judged as to its potential effects on the health of the population and the distribution of those effects within the population. To make it simple, if I were the prime minister or the president and I would say, "Several new factories will be built along this new road. And I'm deeply concerned as you are as the prime minister, that the new road itself might cause water to pool by the sides and lead to an increase in the mosquito population and more malaria. And I'm also quite worried that the new industries that we want them to enable better jobs and employment for our people, might actually create more air pollution. So what I'd like to do is ensure consistent with our laws that we carry out a health impact assessment." And a study would be done, and many of you are familiar with environmental assessments or environmental impact assessments. A study would be done along the same lines. But instead of focusing on the environment, it would focus on the potential impact of these proposed investments on the health of the people, the sources of this impact, and the measures that might be taken to mitigate them and ensure that the full benefits of the project are realized without harming the health of the people. And there's good evidence that these health impact assessments, they are the probably less widely used than we might like, are most successful when they bring together a wide range of stakeholders. They examine social, economic, and environmental factors, among others. They examine whose health is likely to be affected by the investment. And they provide concrete advice to policymakers about the measures that need to be taken to ensure that the investments yield their returns as I mentioned, and do the least possible harm to the health of their population. Now- And it's not hard to imagine, as I mentioned, when in roads. One can imagine another health impact assessment when we think about the widespread use of fertilizers and pesticides, which can be very helpful to producing more crops, and yet, can have very detrimental impacts to human health. And so, if there was an agriculture investment scheme to encourage small farmers, for example, to use more pesticides or fertilizers, one would certainly want a health impact assessment to try to examine what measures can be taken in conjunction with that to reduce the potential negative health impacts. And I'd already talked about manufacturing in roads and won't go on further with that. When we think and when we try to put all of this together and say, now we understand what it is that people get sick and die from, the risk factors and determinants, the importance of moving beyond the Ministry of Health and addressing them and enabling better health. It's also valuable to talk then as we again, put it all together, about a kind of typology of policies that go beyond the Ministry of Health or intersectoral policies. Some might be taxes and subsidies. Some might be regulation and related enforcement. There's also policies related to the built environment. That means the way you build your cities, your sidewalks, your roads, and other physical infrastructure, and policies concerning the provision of information to your people. A very important study came out not long ago from DCP3, the Disease Control Priorities project that has looked since the early 1990's, every so many years, at the health in low and middle income countries. And DCP3 has recommended an intersectoral policy package for which I believe they have suggested there be 79 elements at least at the start. And they have suggested that the evidence shows that these are cost-efficient, can have a very valuable impact at relatively low cost, many of them on enhancing the environment in ways that go beyond the Ministry of Health, and bring together the work of several ministries. And that they're within the capacity of even low income countries to do. And DCP3 has recommended that these be undertaken as expeditiously as possible. The real value of this among others in my view is that we've all known all along, for years and years and years, and decades and decades and decades that young children get diarrhea because they're drinking unsafe water, or sanitation is unsafe. We've known all along about the fact that the Ministry of Health alone cannot address all of the determinants of health that it needs to. And yet, I would suggest that this recent study is especially valuable because for the first time in a long time, it has put together, in a very coherent and organized way, a set of policies that countries might undertake through intersectoral action, to reduce some of the major burdens of disease that require going beyond the Ministry of Health. And I won't go into it at length, but we see, for example, if countries wish to address air pollution, we know there are several of the types of interventions that we just talked about. But it's also clear, they need to be taken by a range of ministries working together. And the same would be true of tobacco smoke, which we've spoken of more than once already. We talked about dietary risks for both underweight and for obesity and overweight. It's quite clear that the Ministry of Health can promote, but it doesn't have the power to go beyond that as we've also suggested in some of the vignettes. And here, we know that to achieve some of these aims that the Agriculture Ministry, the Industry Ministry, the Education Ministry, and probably, the Ministry of Finance will also need to be involved. And we can look as well at injuries for which it's clear that, although the Ministry of Health will promote attention to falls, risks, poisoning, and road traffic accidents, we know that this is very complicated to address, and requires the involvement of a range of ministries like planning the environment, industry transport, and finance if we want to take the most important evidence-based, cost-efficient, doable, sustainable, and fair measures to reduce the risk of disability and deaths that come from road traffic accidents, as well as other injuries. And finally, there's a range of other environmental risks and it's quite clear for them as well that a range of interventions is necessary and warranted, and that a number of ministries will need to be involved if they are to be addressed effectively and efficiently. So, let me end by reminding you of what I hope are the main messages that I tried to bring out in this discussion of intersectoral approaches to enabling better health. First, an important part of the burden of disease can only be addressed through intersectoral approaches. Second, intersectoral action health might be taken through what we call a health in all approach or a whole of government approach. Third, another valuable approach to engaging multiple sectors on health issues can revolve around what we call health impact assessments. And there are a range of intersectoral actions that are essential to address an important share of the determinants of health. And finally, successfully addressing an important share of the burden of disease in today's low and middle income countries requires, I repeat, a broad approach to identify the determinants of disease, disability, and death and then, to act on them across agencies. Thank you very much.