Public Health Intersectoral Strategies in Low-Middle Income Countries (LMIC)
Ligia de Salazar
  • LAST MODIFIED: 11 January 2017
  • DOI: 10.1093/obo/9780199756797-0155


There is a growing literature demonstrating the need for intersectoral actions to address social inequities and improve population health and well-being. Public health has been based on effective interventions in two broad domains: the biomedical domain, responding to diseases and ill-health; and the social, economic, and political domains addressing the structural determinants of health. It is recognized in this article that less rigorous and systematic attention has been paid to health issues in social, economic, and political domains, which is reflected in the literature reviewed to develop this article. The task of implementing intersectoral actions demands structural changes, not only through policies targeted toward health and social protection systems but also in the way resources are organized, coordinated, and distributed. New policies, managerial approaches, and technologies are needed to respond to the demands and challenges to achieve and sustain intersectoral strategies. One of the most outstanding challenges is to deal with complex interventions, implemented in complex systems. Most of the literature reviewed addresses theoretical issues and strategies to implement intersectoral actions; however, there is a big gap between these orientations and the practice, political, and structural conditions needed, which are not present in most lower-middle-income countries. The interpretation of results of any study should be done taking into account both the scope and practical meanings of the terms used. It is imperative, therefore, to focus implementation strategies and mechanisms on creating and sustaining processes of change that fit the needs of political and economic contexts of lower-middle-income countries (LMIC). Few studies focus on the strengthening of country capacity to achieve expected changes and to respond to constraints such as the lack of structures and platforms for dialogue and consensus building, as well as to balance power relationships and creation of legislation-regulations to overcome the traditionally vertical, sectoral, and discipline-oriented programs. This review focuses on experiences to address the above challenges in low- and middle-income countries. It is meant to clearly indicate the need to reflect on our practice, answering questions such as the following: How can LMIC face the constraints and challenges to undertake intersectoral work to reduce health inequities? Can we reduce health inequities without reducing social inequities present in LMIC? Why is it that most of the successful experiences come from pilot projects? Why have we have not been able to scale up? How can LMIC cope with new agendas whose complexity demands a more complex practice? What is the role of the health sector? And finally, are we on the right track?

General Overviews

The social determinants approach, according to Victora, et al. 2011, implies that causal chains run from macro social, political, and economic factors, to the pathogenesis of disease. Blas, et al. 2008 (cited under Process, Results, and Impact Evaluation of Intersectoral Strategies in LMIC) classifies the interventions in three categories: upstream, midstream, and downstream. The first category refer to the reform of fundamental social and economic structures and involve mechanisms for the redistribution of wealth, power, opportunities, and decision-making; the second category is oriented to interventions that “seek to reduce risky behaviors or exposures to hazards by influencing health behaviors or psychosocial factors and/or by improving material working and living conditions.” The majority of experiences cited in this review correspond to “downstream interventions,” which, according to the Blas, et al. 2008, correspond to those that “occur at the micro and/or individual level and mitigate the inequitable impacts of upstream and midstream determinants” (p. 1684). Intersectoral actions require wide political and economic reforms, which are not present in most of LMIC. Readers interested in more structural reforms may review studies done in Brazil (Junqueira 2000 and Magalhães and Bodstein 2009) as well as in Chile (Junqueira 2000 and Solar, et al. 2009). Those interested in challenges and difficulties of intersectoral work to strengthen primary health care, health coverage, and health in all policy strategies, might review Victora, et al. 2011; Mladovsky and Mossialos 2008; Gomes, et al. 2009; and Labonté, et al. 2009. In the same vein, the World Health Organization, Government of South Australia 2010 and Gomes, et al. 2009 call attention to the need for a new social contract among all sectors to strengthen equity and human development, as well as a new form of governance to make sustainable programs.

  • Gomes, N. P., N. M. F. Diniz, C. C. Silva Filho, and J. N. B. Santos. 2009. Enfrentamento da violência doméstica contra a mulher a partir da interdisciplinaridade e intersetorialidade. Revista enfermagem UERJUERJ Nursing Journal 17:14–17.

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    Considers the multicomponent nature of domestic violence as the entry point to highlight the importance of intersectoral and interdisciplinary work. Authors conducted a literature review demonstrating that to address violence, isolated action should be avoided, and different sectors should work together to account for the complexity of this problem.

  • Junqueira, L. A. P. 2000. Intersetorialidade, transetorialidade e redes sociais na saúde. Revista de administração pública 34:35–45.

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    Described intersectorality as processes for integrating skills and experiences and places the Unified Health System in Brazil as a transectoral project: this is because its body of knowledge is not restricted to specific skills but extends to the guarantee of rights. Concepts to understand the complexity of social reality are needed.

  • Labonté, R., D. Sanders, F. Baum, N. Schaay, C. Packer, D. Laplante, and R. S. S. Pooyak. 2009. Aplicación, efectividad y contexto político de la atención primaria integral de salud: resultados preliminares de una revisión de la literatura mundial. Revista Gerencia y Políticas de Salud 8:14–29.

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    Analysis of the Primary Health Care (PHC) strategy after thirty years of Alma Ata declaration is the focus of this study, examining its impact on improving population health, reducing health inequities, and closing knowledge gaps. PHC is conceived as an integral approach oriented to reducing health inequities through community participation, as well as multidisciplinary and trans-sectoral actions.

  • Magalhães, R., and R. Bodstein. 2009. Evaluation of initiatives and intersectoral programs in health: Challenges and learning. Ciência & Saúde Coletiva 14:861–868.

    DOI: 10.1590/S1413-81232009000300021E-mail Citation »

    The focus of this article is on the evaluation of intersectoral initiatives. Social mobilization networks, the profile of the players, types of incentives and levels of institutional integration are treated as crucial elements in the analysis. It is concluded that the interface and dialogue among researchers, evaluators, and decision makers, constitute the central axes for better social and institutional learning.

  • Mladovsky, P., and E. Mossialos. 2008. A conceptual framework for community-based health insurance in low-income countries: Social capital and economic development. World Development 36:590–607.

    DOI: 10.1016/j.worlddev.2007.04.018E-mail Citation »

    Implications of community-based health insurance (CBHI) and universal coverage for health care in LMIC are analyzed, considering contextual factors associated with social determinants. A framework based on social capital theories and economic development to reach sustainable levels of population coverage is used to organize and interpret existing evidence.

  • Solar, O., N. Valentine, D. Albrecht, and M. Rice. 2009. Moving forward to equity in health: What kind of intersectoral action is needed? An approach to an intersectoral typology. Partnership and Intersectoral Action Conference Working Document.

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    An intersectoral typology is described, considering the type and scope of intersectoral initiatives and their implications for the planning, management, and participation of different sectors involved. Discussed are types of engagement of sectors, ranging from information, cooperation, integration, and coordination activities, and the relationship of intersectoral actions to the societal vision of public health, as well as the patterns of social participation.

  • Victora, C. G., M. L. Barreto, M. do Carmo Leal, et al. 2011. Health conditions and health-policy innovations in Brazil: The way forward. Lancet 377:2042–2053.

    DOI: 10.1016/S0140-6736(11)60055-XE-mail Citation »

    In this series of six articles, the authors refer to many challenges closely related to the administration of a complex, decentralized public-health system, which competes with private insurance and institutions. The challenge is recognized as a political one, facing new barriers due to urbanization and social and environmental change, as well as old unresolved health issues.

  • World Health Organization, Government of South Australia. 2010. Adelaide Statement on Health in All Policies moving towards shared governance for health and well being. Health Promotion International 25:258–260.

    DOI: 10.1093/heapro/daq034E-mail Citation »

    The Adelaide Statement on Health in All Policies requires the joining-up and coordination of sectors, as well as the engagement of leaders and policymakers at all levels of government. This change in paradigm implies a new social contract, a new form of governance among all sectors, and leadership within governments to improve human development, sustainability and equity, as well as health outcomes.

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