The future of equity policy in education and health: will intersectoral action be the solution?

This post was first published by NORRAG. It summarises key points from two qualitative systematic reviews of peer-reviewed research on health equity policy (Cairney, St Denny, Mitchell) and education equity policy (Cairney, Kippin) for the European Research Council funded IMAJINE project. Our focus on comparing strategies within sectors supplements a wider focus on spatial justice (and cross-sectoral gender equity) strategies. It is published in conjunction with a GHC and NORRAG joint event “The Future of Equity Policy in Education and Health: Will Intersectoral Action be the Solution?” scheduled for 02 November at 17:00-18:30 CET/Geneva, which will discuss the opportunities and challenges to intersectoral research, practice and policy in education and health. Register for the event here. 

Many governments, international organisations, practitioners, and researchers express high rhetorical support for more equitable policy outcomes. However, the meaning of equity is vague, the choice of policy solutions is highly contested, and approaches to equity policy vary markedly in different policy sectors. 

In that context, it is common for policymakers to back up this equity policy rhetoric with a commitment to intersectoral action and collaboration inside and outside of government, described with terms such as holistic, joined-up, collaborative, or systems approaches to governance. At the same time, it is common for research on policymaking to highlight the ever-present and systemic obstacles to the achievement of such admirable but vague aims.

Our reviews of equity policy and policymaking in two different sectors – health and education – highlights these obstacles in different ways.

In health, the global equity strategy Health in All Policies (HiAP) describes a coherent and convincing rationale for intersectoral action and collaboration inside and outside of government:

1. Health is a human right to be fostered and protected by all governments.
2. Most determinants of health inequalities are social – relating to income, wealth, education, housing, social, and physical environments – and we should focus less on individual choices and healthcare.
3. Policies to address social determinants are not in the gift of health sectors, so we need intersectoral action to foster policy changes, such as in relation to tax and spending, education, and housing. 
4. Effective collaborative strategies foster win-win solutions and the co-production of policy, and avoid the perception of ‘health imperialism’ or interference in the work of other professions. 

Yet, our review of HiAP articles suggests that very few projects deliver on these aims. In some cases, authors express frustration that people in other sectors do not take their health aims seriously enough. Or, those actors make sense of HiAP aims in different ways, turning a social determinants approach into projects focusing more on individual lifestyles. These experiences highlight governance dilemmas, in which the need to avoid ‘health imperialism’ leads to minimal challenges to the status quo, or HiAP advocates seek contradictory approaches such as to formalize HiAP strategies from the top-down (to ensure high-level commitment to reform) and encourage collaborative ‘bottom-up’ approaches (to let go of those reforms to foster creative and locally tailored solutions). 

In education, it is more difficult to identify a single coherent rationale for wider intersectoral action. Within ‘social justice’ approaches, there is some focus on the ‘out of school’ factors crucial to learning and attainment processes and outcomes, particularly when describing the marginalization and minoritization of social groups. There are also some studies of systems-based approaches to education. However, there is a more general tendency to focus on sector-specific activities and solutions, including reforms to education systems and school governance. Further, agenda setting organizations such as the OECD foster the sense that investment in early years education, well governed schools and education systems, and reallocations of resources to boost capacity in schools in deprived areas, can address problems of unequal attainment. 

In other words, in both sectors we can often find a convincing rationale for practitioners in one sector to seek cooperation with other sectors. However, no study describes an effective way to do it, or even progress towards new ways of thinking. Indeed, perhaps the most striking proxy indicator of meaningful intersectoral action comes from the bibliographies of these articles. It is clear from the reading lists of each sector that they are not reading each other’s work. The literature on intersectoral action comes with a narrow sectoral lens. 

In sum, intersectoral action and collaboration remains a functional requirement – and a nice idea – rather than a routine activity.