By Patience Ami Mamattah, University of Ghana & Municipal Director of Health, Ashaiman Health Directorate, Ghana Health Services

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  A key strategy for improving population health at scale and in attaining universal health coverage is Health in All Policies (HiAP). HiAP aims to address the social determinants of health and equity and recognizes that population health is determined by all sectors’ actions and inactions and not just that of the health sector. HiAP therefore requires the commitment and actions of stakeholders across all sectors in a local government setting to program for health improvement most essential for the health of urban populations. While this may differ by city, sectors such as transport, housing, planning, water and sanitation have a significant impact on the health of urban populations, often disproportionately impacting negatively on the health of the poorest. Harnessing commitment, action and key resources from across these sectors through policy interventions and programming, to improve health outcomes, is a core principle of the HiAP approach advocated by the World Health Organization (WHO 2014)[1].  

Multisectoral Collaboration in Ghana

Ghana’s 1992 Constitution, the National Health Policy and the Local Government Act 2016 (Act 936) all alluded to the fact that multisectoral collaboration through HiAP is key in addressing population health challenges at scale and in reducing negative impacts of social and economic determinants of health. However, CHORUS research conducted in the Ashaiman municipality in Greater Accra, Ghana, found that key stakeholders from decentralized departments representing various sectors such as transport, agriculture, veterinary, social welfare and community development, physical planning, works/engineering among others were yet to grasp the concept and appreciate how their policies, plans and programmes can impact on the health of residents in the municipality.  

Study setting

Ashaiman municipality is the fifth fastest-growing urban area in Ghana and the second poorest with multi-dimensional poverty and multiple deprivations including incidence(headcount) and intensity on different aspects of living conditions such as housing, toilet facility, assets, overcrowding, educational attainment and retention, employment, health including health insurance coverage and mortality among others according to the 2021 Population and Housing Census. The municipality has a total population of 228,994 with an annual population growth rate of 4.6%, migration rate (61%) as majority of residents are migrants and not indigens and population density of 10,489 persons/ km2 which covers an area of 45 sq. km width. The municipality is a vibrant commercial hub with small-scale artisan workshops that produce items like buckets, corn-mill funnels, silver pots, cassava graters, and grinders among others (AMPPD/ASHMA, 2021, 2022). Ashaiman is rife with urban poverty resulting in poor housing, congestion, poor hygiene and insanitary practices with 29% of residents dumping and burning refuse indiscriminately resulting in both pollution and periodic outbreak of diseases like measles, rabies, malaria and bird flu. It is not only communicable diseases that the population must contend with, non-communicable diseases like hypertension and diabetes increasing due to changes in diet and exercise patterns in the urban context.   [caption id="attachment_2972" align="alignleft" width="750"] An informal residential area in Ashaiman Municipality, Greater Accra[/caption]  

CHORUS findings

This blog presents findings from a study to explore multisectoral collaboration for population health improvement in the municipality and find out from a range of stakeholders what they perceive as the challenges to multisectoral collaboration. Our research showed a lack of understanding and poor awareness of HiAP with stakeholders not appreciating the role of their sector in determining the health of urban populations. This was underpinned by a lack of capacity and resources to assess and respond to the impacts of different sectors on health. Across the municipality, we found disjointed, parallel and non-harmonized policies and programmes and frequently sector staff were unaware of the policy or national approach to HiAP. Concerns of corruption and lack of transparency fueled a reluctance to collaborate. This was further undermined by an absence of direct policy intervention or implementation directives to drive multisectoral collaboration at the city's local government level.

Strengthening multisectoral action for HiAP

Regardless, key enablers exist to enable multisectoral action for health through HiAP. These include the prevailing favorable policy environment to support multisectoral collaboration. Governance structures such as the Municipal Development Planning and Coordinating Unit (MPCU) provide a valuable forum for multi-sectoral collaboration. Our study acted as a catalyst for the municipality’s MPCU to expand its membership from 13 to 20 members representing social and economic sectors within the local government setting and whose actions and inactions impact health. Sustaining awareness creation about multisectoral collaboration, capacity building in terms of knowledge and application of HiAP framework by all sectors as well as development of an indicator monitoring framework that is linked to urban health indicators used in assessing performance of duty bearers within the local government setting as a key performance assessment tool for stakeholders’ unique contribution to population health improvement per their application of HiAP within the settings.  

To Conclude

While this study was exploratory in nature, the process has had an impact in creating awareness among stakeholders of HiAP and re-orienting their approaches through multisectoral collaborative programming for population health. Not only that but also stakeholders can now also see it as a key strategic framework for population health improvement. Such work needs to be conducted with each municipality within Greater Accra and other urban areas to allow all sectors to work together to protect and promote the health of city residents.   [1] WHO 2014 HiAP Statement https://www.who.int/publications/i/item/9789241506908 Photo Credit: Patience Ami Mamattah Banner image shows a market in Ashaiman Municipality, Greater Accra