Coordinating Multiple Programs and Services:

Exploring Coherence and Fit

School Health 2008

Nancy Edwards, RN, PhDSchool of Nursing and Department of

Epidemiology and Community Medicine

Why the Shift to Comprehensive School Health Programs?

• Comprehensive programs – more than a basket of interventions

• Reflects a deeper understanding of underlying determinants across the life course

• “Comprehensive pediculosis screening programs for elementary schools.”

WHO Commission on Social Determinants of Health

Interim Statement (2007)

“Action is needed on the determinants of health – from structural conditions of society to the more immediate influences, at all levels from global to local, across government and inclusive of all stakeholders from civil society and the private sector. Key to multilevel action is coherence.”

Public health core competencieshttp://www.phac-aspc.gc.ca/ccph-cesp/stmts-enon-

eng.html#4

• Assess, analyze and apply information

• Policy and program planning, implementation and evaluation

• Partnerships, collaboration and advocacy

• Communication

• Leadership

Poverty in the midst of wealth

Synergistic or antagonistic with what?

• Synergies between interventions and context may be most critical.

Constraints on Achieving Coherence in

Comprehensive Programs

• Sector-specific planning• Focus on proximal rather than distal influences• Focus on familiar rather than unfamiliar

determinants• Dynamic changes – leadership, political

processes• Growing inequalities and inequities • Disengaged families and communities

People’s Republic of China

Yunnan Maternal &

Child HealthProject,Yunnan

Province,China

Yunnan Maternal &

Child HealthProject,Yunnan

Province,China

Beijing

Yunnan Maternal and Child Health ProjectYunnan Maternal and Child Health Project

Purpose:Purpose: To improve the quality of village life and promote the development of productivity and social prosperity in

poor ethnic minority counties in Yunnan Province

Participatory training for grassroots workers

Essential MCH equipment

Strengthen MCH referral mechanisms

Participatory monitoring and

evaluation

Co-constructing the language to describe core project elements

• Sharing experience• Modeling different

forms of inquiry• Surfacing underlying

assumptions

Threats to Project Sustainability(Edwards & Roelofs, CJPH, 2006)

• Uneven support for the training innovation across system levels

• Work unit leaders expressed doubt about the utility and appropriateness of participatory approaches for village health workers

• Supervisory approaches mirrored the authoritative and didactic approaches to training that were standard practice

• Significant national reforms increased work demands and threatened job security

• Multi-level support and fit with cultural context

Developing Management Systems with Cross-Cultural Fit (Edwards & Roelofs, Intl

J Health Plann Mgmt, 2006)

• System dimensions– Administrative and financial systems– Governance structures– Communication systems– Monitoring and reporting systems– Human resource infrastructure

• Areas of assessment– Cultural context– Capacity– Rapid systems change– Accountability

Cross-cultural fit of management systems - examples

• Where do the negotiation and expression of dissenting views happen: during public meetings, in private meetings or behind closed doors?

• How is approval for a change in policies communicated between different levels of the system?

• How is the balance between responsibility and accountability shared between managers and working level staff?

Yunnan, China – Lessons Learned

• Authentic participatory approaches must be infused through all levels of the work including management structures, decision-making processes & evaluation approaches

• A deep mutual understanding of an intervention must be co-created by partners

• Never assume the intervention has “taken hold”

Coherence and FitWhat is the relevance to School Health?

• Project fit must be continuously co-created by partners within a dynamic context

• Fit can be examined in more depth when underlying assumptions are surfaced

• Building project coherence requires attention to both vertical and horizontal alignments

• Governance and evaluation systems for comprehensive programs need to bridge sectors and levels