Abstracts

Introduction

Over the past two decades, Brazil has been experiencing an increase in the number and coverage of national and local social policies aimed at improving Brazilian social indicators. Although the national social and economic situation has been improving steadily, Brazil still has to overcome one of its most striking problems: inequity¹1 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian Health System: history, advances and challenges. Lancet 2011; 377(9779):1778-1797.^,22 Organización de las Naciones Unidas (ONU) -Habitat. Estado de Las Ciudades de América Latina Y El Caribe. Rumo a una nueva transición urbana. 2012. [accessed 2013 Mar 17]. Available from: http://www.onuhabitat.org/index.php?option=com_content&view=article&id=859:onu-habitat-presenta-el-estado-de-las-ciudades-de-america-latina-y-el-caribe&catid=32:genero&Itemid=210
http://www.onuhabitat.org/index.php?opti... .

The 1988 Brazilian Constitution states that the objectives of the Republic are to eradicate poverty and marginalization and to reduce social and regional inequities. To achieve these goals, the Constitution recognizes health, education, food security, social assistance, social security, housing, healthy environment, leisure, security and work as social rights for all citizens³3 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out..

The main strategy of the Brazilian government to support social rights, and to take action against inequity, has been the promotion of social and economic public policies³3 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.. These policies have been formulated, executed and coordinated by sectoral ministries, secretariats and other organizations of the public administration in all federative levels, particularly in the states and municipalities. The administrative organization based in sectors has been a common feature of modern federative nations, but it may, per se, jeopardize the sharing of governance power, consensus building and funding of intersectorial policies. Additionally, in Brazil, political issues may contribute to this unfavorable scenario because different political parties usually occupy different administrative levels and different institutions within a level. As a result, institutional fragmentation in social protection policies has led to poor outcomes in tackling complex problems, such as health inequity¹1 Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian Health System: history, advances and challenges. Lancet 2011; 377(9779):1778-1797.. From the health sector point of view, social rights should not be understood as rights to be fulfilled separately, but instead, as determining factors of the health-disease process.

In a recent publication, Spiegel et al.⁴4 Spiegel J, Alegret M, Clair V, Pagliccia N, Martinez B, Bonet M, Yassi A. Intersectoral action for health at a municipal level in Cuba. Int J Public Health 2012; 57(1):12-23. highlighted that, to fight health inequity, it is imperative that public policies address social determinants of health intersectorally. The authors noted that regular engagement of different sectors in dealing collaboratively with health determinants at the municipal level in Cuba contributed to a reduction in health inequity and to provision of high standards of health. In a similar vein, Franco-Giraldo and Álvarez-Dardet⁵5 Franco-Giraldo A, Álvarez-Dardet C. Derechos Humanos, una oportunidade para las politicas públicas en salud. Gac Sanit 2008; 22(3):280-286. had emphasized the perspective of public health policies based on human rights. This kind of approach might shed light on the relationship between public policies and the practice of human rights, beyond the right to health. It is the fulfillment of human rights considered as a whole that allow a better protection of the right to health itself and the promotion of social equity.

The importance of intersectoral policies for health equity was reiterated in the Rio Declaration on Social Determinants of Health, signed by all World Health Organization (WHO) members in 2011⁶6 World Health Organization (WHO). Rio Political Declaration on Social Determinants of Health, Rio de Janeiro, Brazil. 2011. [accessed 2013 Feb 20]. http://www.who.int/sdhconference/declaration/en/
http://www.who.int/sdhconference/declara... . The principles affirmed by the Declaration of Alma Alta⁷7 World Health Organization (WHO). Declaration of Alma Ata. 1978. [accessed 2013 Feb 20]. Available from: http://www.who.int/publications/almaata_declaration_en.pdf
http://www.who.int/publications/almaata_... were then reinforced, i.e., integrated practices aiming at health promotion, health protection and health recovery and rehabilitation should consider the interrelations between the bio psycho social determinants of the health-disease process.

Putting public policies with integrated purpose into practice poses substantial challenges. Several studies have discussed different experiences of intersectoral practices⁸8 Solar O, Irwin A. A conceptual framework for action on the social determinants of health: discussion paper for the commission on social determinants of health. Geneva: WHO; 2007.

9 Giovanella L, Magalhães de Mendonça MH, Almeida PF, Escorel S, Senna MCM, Fausto MCR, Delgado MM, Andrade CLT, da Cunha MS, Martins MIC, Teixeira CP. Family health: limits and possibilities for an integral primary healthcare approach in Brazil. Cien Saude Colet 2009; 14(3):783-794.

10 Bacigalupe A, Esanaola S, Martín U, Zuazogoitia J. Learning lessons from past mistakes: how can health in all policies fulfill its promises? J Epidemiol Community Health 2010; 64(6):504-505.

11 Moll J, Rabelo MKO. (Re)conhecendo o território escolar e mapeando o sentido do ser jovem: contribuições dos programas e projetos intersetoriais para recuperação das vulnerabilidades do escolar. Cien Saude Colet 2010; 15(Supl. 2):3020-3026.

12 Puska P, Stahl T. Health in all policies - the Finnish initiative: background, principles, and current issues. Ann Rev Public Health 2010; 31:315-328.^-1313 Ramírez NA, Ruiz JP, Romero RV, Labonté R. Comprehensive Primary Health Care in South America: contexts, achievements and policy implications. Cad Saude Publica 2011; 27(10):1875-1890., but knowledge about the mechanisms that may facilitate interrelations across sectors is scarce.

Based on a two-phase study, this paper aims to analyze and to discuss intersectoral health-related policies (IHRP) by applying legal and theoretical conceptual frameworks to a case study on public social policies in Piracicaba, southeastern region of Brazil. By doing so, the authors tried to advance the understanding of the managerial and political needs to pursue intersectoral practices.

Methods

The first phase of the study comprised analysis of part of the results of a two-year research project (2008-2009) that investigated social policies in the municipality of Piracicaba, Sao Paulo State, Brazil. The second phase focused on identifying the legal and theoretical conceptual frameworks used to characterize IHRP. Finally, we use the lessons learnt from the case of Piracicaba and recognition of the conceptual frameworks to propose three main types of IHRP as a contributing strategy to improve the planning and implementation of social policies by governments.

The case of Piracicaba

Piracicaba, a middle-sized city (estimated population 365.440 in 2008), was selected due to the high level of interest expressed by local administrators in collaborating on research in the field of intersectorality. The main objective of the case study was to explore the role of health workers, at the primary health care level, in disseminating information on social policies to the local communities. For the purpose of this study, social policies were defined as planned actions of particular interventions directed to specific populations that present health-related demands.

The methodological strategy consisted of a "case study" using quantitative and qualitative approaches and converging information sources¹⁴14 Serapioni M. Métodos qualitativos e quantitativos na pesquisa social em saúde: algumas estratégias para a integração. Cien Saude Colet 2000; 5(1):187-192.. Ethical approval was given by the Ethics Committee of the Medical School of São Paulo, University of São Paulo. Secondary data consisted of public documents which allowed us to map the social policies in place in Piracicaba during the years 2008 and 2009. A list of social policies was generated. Policy makers and public managers completed written, semi-structured interviews. These interviews included questions on the target population, coverage, budget and duration to characterize the policies. Social policies run by the non-public sector such as non-governmental organizations and religious institutions, were not considered in our analysis due to the lack of systematic information about their performance.

Based on the identified local social policies in place in Piracicaba, we proposed the development of an information tool to help health workers to inform primary health care users on the available social policies relevant to their needs. The guide was made available in printed and electronic versions and was adopted by the primary health care team in their work routine and helped them be aware of the local social policies.

Results and discussion

Eight out of the 11 municipal secretariats offered social policies to Piracicaba's inhabitants. A total of 37 social policies were included in our guide and they were drawn from Health (13 policies), Social Assistance (15), Education (2), Culture (1), Housing (1), Employment (1), Sports (3) and Environment (1). Agriculture, Planning and Industry and Commerce did not promote social policies during the study period. Although several policies were identified, their delivery was unbalanced; the Health and Social Assistance secretariats were by far the main social policy promoters.

The thorough review of the information collected through interviews with policy managers allowed us to classify the 37 social policies according to their target population. Results are shown in Table 1.

No rational decision-making process to initiate, plan and implement a social policy was evident. A selective approach to social policies was observed: while some populations, such as drug abusers, had no social policies directed to their needs, some specific groups, such as disabled people and children, were targeted by several policies. It should be noted that by classifying social policies based on their target populations, overlap between categories may have occurred.

Another important finding was that the only intersectoral practice reported was a formal exchange of information on health-related policies between the Health and Social Assistance secretariats. However, these efforts did not result in joint planning of intersectoral policies.

These results were surprising because despite the political will of the local government to approach complex problems with intersectoral policies, most public policies in Piracicaba were fragmented in their origination and implementation. Individual sectoral goals were predominant, without coordination or integration between secretariats. There was thus a need for the government to improve its practices. These findings motivated the current study, which tried to move understanding of IHRP forward. Analyzing the advances in the legal and theoretical landmarks and characterizing different types of IHRP may be considered important steps to building efficient intersectoral practices.

Legal and theoretical conceptual frameworks to understand IHRP

The most relevant international legal documents that comprise conceptual frameworks on IHRP are: WHO's Constitution, which established health as a human right and government responsibility¹⁵15 World Health Organization (WHO). Constitution of the World Health Organization. 1946. [accessed 2013 Feb 20]. Available from: http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf
http://apps.who.int/gb/bd/PDF/bd47/EN/co... ; the International Covenant on Economic, Social and Cultural Rights¹⁶16 United Nations Human Rights (UN). International Covenant on Economic, Social and Cultural Rights. 1966. [accessed 2013 Feb 20]. Available from: http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx
http://www.ohchr.org/EN/ProfessionalInte... ; the International Conference on Primary Health Care⁷7 World Health Organization (WHO). Declaration of Alma Ata. 1978. [accessed 2013 Feb 20]. Available from: http://www.who.int/publications/almaata_declaration_en.pdf
http://www.who.int/publications/almaata_... ; and the First International Conference on Health Promotion¹⁷17 World Health Organization (WHO). The Ottawa Charter for Health Promotion. 1986. [accessed 2013 Feb 20]. Available from: http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
http://www.who.int/healthpromotion/confe... . These documents provide a solid legal ground for IHRP as they underline the notion that public policies should take the social determinants on health into account. They also suggest that global health is one of the most important social goals, emphasizing that to achieve it, there is a need for action from several other social and economic sectors in addition to the health sector, i.e., it requires intersectoral action. Recently, the Commission on Social Determinants of Health¹⁸18 Lee JW. Public Health is a social issue. Lancet 2005; 365(9464):1005-1006. and the Rio Political Declaration on Social Determinants of Health⁶6 World Health Organization (WHO). Rio Political Declaration on Social Determinants of Health, Rio de Janeiro, Brazil. 2011. [accessed 2013 Feb 20]. http://www.who.int/sdhconference/declaration/en/
http://www.who.int/sdhconference/declara... reinforced the principles brought about by the primary documents. They stated that global health improvement depends not only on equitable and effective health systems, but also on actions involving sectors other than health.

The main legal landmarks on IHRP were accompanied by a relevant theoretical publication reporting on how governments put intersectoral experiences for health into practice. The theoretical conceptual framework for IHRP is based on the concepts of Intersectoral Action for Health (IAH)⁴4 Spiegel J, Alegret M, Clair V, Pagliccia N, Martinez B, Bonet M, Yassi A. Intersectoral action for health at a municipal level in Cuba. Int J Public Health 2012; 57(1):12-23.^,1919 Shankardass K, Solar O, Murphy K, Greaves L. O'Campo P. A scoping review of intersectorial action for health equity involving governments. Int J Public Health 2012; 57(1):25-33.^,2020 Potvin L. Intersectoral action for health: more research is needed! Int J Public Health 2012; 57(1):5-6. and of Health in All Policies (HiAP)¹²12 Puska P, Stahl T. Health in all policies - the Finnish initiative: background, principles, and current issues. Ann Rev Public Health 2010; 31:315-328.^,1818 Lee JW. Public Health is a social issue. Lancet 2005; 365(9464):1005-1006..

IAH is defined as any action in which the health sector and other sectors collaborate to pursue health goals. It includes actions which are coordinated by other sectors and are considered as potential effort to fulfill the right to health²¹21 World Health Organization (WHO), Public Health Agency of Canada. Health equity through intersectoral action: an analysis of 18 country case studies. 2008. [accessed 2013 Feb 20]. Available from: http://www.who.int/social_determinants/resources/health_equity_isa_2008_en.pdf
http://www.who.int/social_determinants/r... . In other words, IAH can be understood as intersectoral public policies that take into account health matters in their development.

A scoping review of IAH for health equity involving governments was carried out by Shankardass et al.¹⁹19 Shankardass K, Solar O, Murphy K, Greaves L. O'Campo P. A scoping review of intersectorial action for health equity involving governments. Int J Public Health 2012; 57(1):25-33.. The authors analyzed 128 articles and acknowledged four patterns of relationships for intersectoral policies, within health and non-health government sectors. They were information sharing, cooperation, coordination and integration. These patterns provided a better understanding of the main mechanisms used by governments to develop and implement intersectoral policies on the social determinants of health⁸8 Solar O, Irwin A. A conceptual framework for action on the social determinants of health: discussion paper for the commission on social determinants of health. Geneva: WHO; 2007..

Puska and Stahl¹²12 Puska P, Stahl T. Health in all policies - the Finnish initiative: background, principles, and current issues. Ann Rev Public Health 2010; 31:315-328. used another approach, based on a scientific background in public health sciences and epidemiology, to explore the concept of Health in All Policies (HiAP). They suggested that HiAP are public policies which are coordinated by non-health sectors but have an impact on the social determinants of health.

Whereas IAH have health as the main target, HiAP offer a broad understanding on IHRP by identifying, in the health and other sectors, ways to achieve health goals by tackling the social determinants of health equity. By applying these different intersectoral approaches to the concept of patterns of relationships for intersectoral policies, intersectoral possibilities of action aimed at developing more efficient health results can be identified.

Identifying types of intersectoral health-related policies

There is a need for governments to develop public policies which address social determinants of health and health equity. By analyzing the case study of Piracicaba in the light of the conceptual frameworks, we recognized three general types of IHRP.

The most common type of IHRP are health policies run by the health sector. In such cases, the health sector is the protagonist and coordinator, but needs to co-operate with non-health sectors to succeed¹⁰10 Bacigalupe A, Esanaola S, Martín U, Zuazogoitia J. Learning lessons from past mistakes: how can health in all policies fulfill its promises? J Epidemiol Community Health 2010; 64(6):504-505.. Several studies cited examples of this type of intersectoral health policy, especially in relation to issues such as mental health²²22 Jenkins R, Hashmat A, Loza N, Siekkonen I, Sorour E. Mental Health policy and development in Egypt - integrating mental health into health sector reforms 2001-9. Int J Ment Health Syst 2010; 4:17., dengue control²³23 González Fernández MI, Orozco Núñez E, Cifuentes E. Policy analysis of the dengue control program in Mexico. Rev Saude Publica 2010; 44(6):1-7.^,2424 Sanchez L, Perez D, Perez T, Sosa T, Cruz G, Kouri G, Boelaert M, Van Der Stuyft P. Intersectoral coordination in Aesdes aegypti control. A pilot project in Havana City, Cuba. Trop Med Int Health 2005; 10(1):82-91.; health promotion²⁵25 Rutten A, Abu-Omar K, Gelius P, Dinan-Houng S, Frandin K, Hopman-Roch M, Young A. Policy Assessment and policy development for physical activity promotion: results of an exploratory intervention study in 15 European countries. Health Res Policy Syst 2012; 10:14.; primary health care¹³13 Ramírez NA, Ruiz JP, Romero RV, Labonté R. Comprehensive Primary Health Care in South America: contexts, achievements and policy implications. Cad Saude Publica 2011; 27(10):1875-1890., cardiovascular health²⁶26 Fuster V, Kelly BB, Vedanthan R. Global cardiovascular health: urgent need for intersectoral approach. J Am Coll Cardiol 2011; 58(12):1208-1210., cancer disparities²⁷27 Ramanadhan S, Salhi C, Achille E, Baril N, D'Entremont K, Grullon M, Judge C, Oppenheimer S, Reeves C, Savage C, Viswanathet K. Addressing cancer disparities via community network mobilization and intersectoral partnerships: a social network analysis. PLoS One 2012; 7(2):e32130. and childhood obesity²⁸28 Hendriks AM, Gubbels JS, De Vries NK, Seidell JC, Kremers SPJ, Jansen MWJ. Interventions to promote an integrated approach to public health problems: an application to childhood obesity. J Environ Public Health 2012; 913236..

The second most common IHRP are those with a sector other than health as the protagonist. Although not directly concerned with health, these policies have to consider health issues because they may affect health outcomes or be affected by them²⁹29 Burlandy L. Construction of the food and nutrition security policy in Brazil: strategies and challenges in the promotion of intersectorality at the federal government level. Cien Saude Colet 2009; 14(3):851-860.. The concept of HiAP can be directly applied to this type of IHRP. Examples include nutrition²⁸28 Hendriks AM, Gubbels JS, De Vries NK, Seidell JC, Kremers SPJ, Jansen MWJ. Interventions to promote an integrated approach to public health problems: an application to childhood obesity. J Environ Public Health 2012; 913236.^,3030 Van Herten LM, Reijneveld SA, Gunning-Schepers LJ. Rationalising chances of success in intersectoral health policy making. J Epidemiol Community Health 2001; 55(5):342-347., agriculture³¹31 Hawkes C, Ruel M. The links between agriculture and health: an intersectoral opportunity to improve the health and livelihoods of the poor. Bull WHO 2006; 84(12):984-990., environment³²32 Clavier C, Gendron S, Lamontagne L, Potvin L. Understanding similarities in the local implementation of a healthy environment programme: insights from policy studies. Soc Sci Med 2012; 75(1):171-178. and educational policies¹¹11 Moll J, Rabelo MKO. (Re)conhecendo o território escolar e mapeando o sentido do ser jovem: contribuições dos programas e projetos intersetoriais para recuperação das vulnerabilidades do escolar. Cien Saude Colet 2010; 15(Supl. 2):3020-3026..

The third type of IHRP, which we call literal intersectoral policy, refers to public policies that do not have any specific sector as the protagonist. In other words, the planning and implantation of this kind of policy must be shared - literally, joining different sectors. Due to their complex nature, this type of policy is uncommon and not easily acknowledged. However, at least three examples can be cited: public disasters³³33 World Health Organization (WHO). International Health Regulations. 2005. Second edition. [accessed 2013 Feb 20]. Available from: http://whqlibdoc.who.int/publications/2008/9789241580410_eng.pdf
http://whqlibdoc.who.int/publications/20... , violence³⁴34 Matzopoulos R, Browman B, Mathews S, Myers J. Applying upstream interventions for interpersonal violence prevention: an uphill struggle to in low-middle income contexts. Health Policy 2010; 97(1):62-70. and drug control³⁵35 Topp L, Mcketin R. Supporting evidence-based policy-making: a case study of the illicit drug reporting system in Australia. In: United Nations Office on Drugs and Crime. Bulletin on Narcotics, Volume LV, n. 1 and 2: The Practice of Drug Abuse Epidemiology. [accessed 2013 Aug 20]. Available from: https://www.unodc.org/pdf/bulletin/bulletin_2003_01_01_1.pdf#page=31
https://www.unodc.org/pdf/bulletin/bulle... .

Identifying these types of IHRP is important in that it can lead to better understanding of the practical aspects of planning political and managerial structure of local, regional or national governments in dealing with intersectoral policies. For each of them, the different patterns of relationships described in 2012 by Shankardass et al.¹⁹19 Shankardass K, Solar O, Murphy K, Greaves L. O'Campo P. A scoping review of intersectorial action for health equity involving governments. Int J Public Health 2012; 57(1):25-33. must be considered (Chart 1).

From theory to practice: pathways to implement intersectoral health-related policies

As legal and theoretical frameworks show, intersectoral policies are important to improve the health of populations and promote health equity in Brazil and elsewhere. By identifying three types of IHRP and relating each type to one or more patterns of relationship, it may be easier to acknowledge the practical steps of the organization of intersectoral policies, helping governments to develop IHRP more efficiently.

Although we were able to identify several legal and theoretical frameworks which support the need to develop IHRP, in the case study of Piracicaba there was an important gap between those frameworks and government practices. This gap may have been caused, at least partially, by the difficulty in understanding the pathways that might be followed by governments to implement IHRP successfully.

The starting point of any IHRP includes the clear definition of public policy objectives and the identification of the sectors that need to be involved. By doing this, policy makers can comprehend the relationship between the health goals and the specific policy to be implemented. Moreover, identifying which type of IHRP best fits the policy objectives will facilitate structuring of government organizations to put policy into practice.

As Chart 1 shows, if the main goals to be achieved are directly related to health, it must be established that the health sector will coordinate the IHRP, as well as defining the patterns of relationships that are going to be used to articulate the health sector with the other sectors involved. The same kind of process should be used when a non-health sector (e.g. housing) has clear responsibility for the IHRP. In this case, the non-health sector will be the coordinator of the policy and the above-mentioned patterns of relationship will apply. On other hand, if the objectives of the health related policy to be implemented point to the need for a literal IHRP, it might be necessary to create a special intersectoral structure to coordinate, evaluate and execute this specific intersectoral policy.

By applying these methods of analysis to the Piracicaba case, two types of IHRP were identified as being practiced by the local government. Thirteen policies could be classified as the first type (policies coordinated by the health sector). Twenty-four policies could be classified as the second type (coordinated by non-health sectors). The third type of IHRP, the literal intersectoral policies, was not seen in Piracicaba.

The only pattern of relationships for intersectoral action reported was an exchange of information between the Health and Social Assistance secretariats, the most active sectors in Piracicaba. Although they did not formulate or execute policies together, they shared formal information on their priorities for action. This practice could be interpreted as a first step to integrating these two sectors. As far as the second type of IHRP is concerned, non-health sectors did not initiate any moves towards intersectoral action.

It is noteworthy that there was an imbalance in the distribution of social policies in Piracicaba. While some groups, such as disabled people and children, were targeted by several policies, other groups, such as drug abusers, were not covered by any social policy. This finding demonstrates that poor intersectoral practice is preventing the local government from building a more comprehensive plan to deal successfully with their public health issues.

It is, however, not surprising that no literal intersectoral policies (third type) were found. The political challenges and administrative technologies involved in this type of intersectoral policy require an administrative structure and a work culture that is not usually seen. Intersectoral practice demands an institutionalized administrative structure specifically created to facilitate intersectoral relationships. The political will to tackle complex problems in Piracicaba was not enough to guarantee intersectoral action.

Final considerations

Although governments and scientists recognized the need for IHRP to achieve health equity for future decades, our findings illustrate that putting IHRP in place is not an easy task. Piracicaba and most middle-sized cities face complex problems but local governments usually deal with such problems on a sectoral basis. By functioning in a fragmented way, different sectors may be unaware that they are targeting their actions towards the same populations as other sectors.

One way to promote IHRP is to create institutional tools to formalize intersectoral strategy as a political and administrative reality. To influence health determinants it is necessary, then, to put together health sector and non-health sectors with the same goals, sometimes even under the same public authority, or under a shared coordination practice. Public policies are only able to promote positive results in health development if policy makers are capable of organizing different sectors' skills and of orienting them towards the same goals. To improve the efficiency of IHRP we must consider the need to create specific intersectoral institutions or mechanisms within the government structure. This will allow different sectors to work together to define goals, plan actions and define financing, as well as to evaluate the results.

By analyzing the local level practices on IHRP and by combining them with the legal and theoretical frameworks, we could identify three general types of IHRP. For each type, different patterns of intersectoral relationships and different coordination structures may be needed, helping to clarify the planning and managerial strategies required to improve intersectoral actions for health and also the role that health sector must play in different types of IHRP. When the demand is for an intersectoral health policy, the health sector must be the protagonist and create the conditions for intersectoral relationships. When it is the health in all policies type of IHRP, governments may need to establish institutional mechanisms to implement coordination, cooperation, integration and information sharing among all the sectors involved. Finally, when the demand is for a literal intersectoral policy, governments may consider an intersectoral administrative structure capable of bringing together different sectors in order to formulate and coordinate the policy, sharing responsibility evenly.

Comprehension of different general types of IHRP and the necessary pathways to develop successful intersectoral public policies may contribute to better efficiency and coverage of social policies that affect health equity and its social determinants positively. Eventually, this will lead to more equitable health outcomes.

Acknowledgements

This study was made possible through funding provided by the State of São Paulo Research Foundation (FAPESP). We acknowledge the support given by the Piracicaba government, mostly notably the secretariats of Health and Social Assistance.

References

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