Elusive implementation: an ethnographic study of intersectoral policymaking for health

Abstract

BackgroundFor more than 30 years policy action across sectors has been celebrated as a necessary and viable way to affect the social factors impacting on health. In particular intersectoral action on the social determinants of health is considered necessary to address social inequalities in health. However, despite growing support for intersectoral policymaking, implementation remains a challenge. Critics argue that public health has remained naïve about the policy process and a better understanding is needed. Based on ethnographic data, this paper conducts an in-depth analysis of a local process of intersectoral policymaking in order to gain a better understanding of the challenges posed by implementation. To help conceptualize the process, we apply the theoretical perspective of organizational neo-institutionalism, in particular the concepts of rationalized myth and decoupling.MethodsOn the basis of an explorative study among ten Danish municipalities, we conducted an ethnographic study of the development of a municipal-wide implementation strategy for the intersectoral health policy of a medium-sized municipality. The main data sources consist of ethnographic field notes from participant observation and interview transcripts.ResultsBy providing detailed contextual description, we show how an apparent failure to move from policy to action is played out by the ongoing production of abstract rhetoric and vague plans. We find that idealization of universal intersectoralism, inconsistent demands, and doubts about economic outcomes challenge the notion of implementation as moving from rhetoric to action.ConclusionWe argue that the ‘myth’ of intersectoralism may be instrumental in avoiding the specification of action to implement the policy, and that the policy instead serves as a way to display and support good intentions and hereby continue the process. On this basis we expand the discussion on implementation challenges regarding intersectoral policymaking for health.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-2864-9) contains supplementary material, which is available to authorized users.

Factors influencing delivery of intersectoral actions to address infant stunting in Bogotá, Colombia – a mixed methods case study.

“…There were however concerns over how to implement ISA. A similar situation was explored in an ethnographic study by Holt et al, who challenged the notion that ISA can be more discursive than practical and thus di cult to implement (5). Although initiatives for intersectoral or multisectoral strategies to tackle stunting may be approved by the parties concerned, there is a clear need to understand and implement them beyond political will (36).…”

“…Colombia has established ISA as a core tool for development and promotes monitoring and evaluation of ISA to achieve the Sustainable Development Goals (SDG) (23). There is an emphasis worldwide on documenting the challenges in 'implementation' of ISA and their 'effectiveness' of outcomes (4,5,24).…”

Percepção da equipe multidisciplinar sobre a estrutura dos serviços de saúde mental: estudo fenomenológico

“…For social reintegration to become possible, intersectoral actions are needed to overcome the fragmentation of care based on the articulation of different sectors of society and dialogue between institutions, governments and individuals to formulate public policies with the aim of improving the condition health status of the population (11)(12) . For this, it is necessary to overcome the idealization of this process and transcend the good intentions of the sectors involved to the detriment of the specification of the actions (13).…”

Legitimising Inter-Sectoral Public Health Policies: A Challenge for Professional Identities?

“…However, although the health sector is dominant in many Norwegian municipalities, public health does not represent a defined discipline or profession. There are ongoing debates in the field about its aims, content, priority areas, procedures and ways of working [30,34,12], and public health coordinators and others find this disorientation or complexity challenging [35,36]. Interestingly, we might therefore ask whether the actors promoting HiAP (which might threaten collaborators' professional identities) actually struggle with finding their own professional identities themselves.…”

“…Inspired by new institutionalism, we regard organisations and their agents to be dependent on their institutional environment and on gaining legitimacy not only to succeed economically but also to survive [8][9][10]. To examine HiAP, other scholars have used institutional perspectives, such as path dependency and rationalised myth [11][12], institutional logics [13] and translation of organisational ideas [14][15]. By contrast, studies that apply a legitimacy perspective have been difficult to find.…”