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Analysis The World We Want

Tackling the politics of intersectoral action for the health of people and planet

BMJ 2022; 376 doi: (Published 26 January 2022) Cite this as: BMJ 2022;376:e068124

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  1. Kent Buse, professor1,
  2. Göran Tomson, professor23,
  3. Shyama Kuruvilla, senior strategic adviser4,
  4. Jemilah Mahmood, executive director5,
  5. Anastasia Alden, communications manager1,
  6. Maarinke van der Meulen, programme manager6,
  7. Ole Petter Ottersen, professor2,
  8. Andy Haines, professor7
  1. 1George Institute for Global Health, Imperial College London, London, UK
  2. 2Karolinska Institutet, Stockholm, Sweden
  3. 3Swedish Institute for Global Health Transformation, Royal Swedish Academy of Sciences, Stockholm, Sweden
  4. 4World Health Organization, Geneva, Switzerland
  5. 5Sunway Centre for Planetary Health, Sunway University, Malaysia
  6. 6George Institute for Global Health, Sydney, Australia
  7. 7London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to: K Buse KBuse{at}

Kent Buse and colleagues argue that unlocking the potential for intersectoral action on climate and health requires thinking politically about its facilitators and barriers

Human activities are wreaking extensive damage on the natural systems of the planet and undermining the prospects for the health of current and future populations. The 2021 report of the Intergovernmental Panel on Climate Change provided further evidence of the increasing urgency of responding to the threats posed by climate change—which the UN secretary general labelled “a code red for humanity.”12

The UN climate conference in Glasgow (COP26) laid bare the highly political nature of international cooperation on climate change, and the futility of failing to recognise that the health and sustainability of the environment are the cornerstone of equitable development.34 The politics inherent in intersectoral action on climate and health may be less visible than COP26 but must be addressed to deliver the goals of the Paris agreement (box 1).7

Box 1

Climate emergency imperative for intersectoral action56

  • Both adaptation and mitigation are required to reduce the health effects of climate change, but to be effective they must be transformational, targeting the political and economic systems that maintain the status quo

  • Adaptation aims to manage the risks posed by environmental changes. Mitigation aims to cut greenhouse gas emissions that are causing climate change. Increasingly adaptation and mitigation need to be integrated to minimise trade-offs and support equitable solutions. Both require actions across multiple sectors, including energy, housing, industry, transport, waste, water and sanitation, health, and agriculture, food, and land use

  • Many of the actions also have benefits for health—for example, by reducing air pollution from burning fossil fuels, promoting physical activity through increases in active transport, and supporting healthy, low environmental impact dietary choices

  • Well designed and implemented carbon pricing and subsidy removal can accelerate intersectoral action by redirecting resources to actions that improve health equity as well as cutting greenhouse gas emissions

  • Health indicators should be integrated into reporting of efforts to reduce emissions and build resilience to climate change as well as fostering planetary health more widely


International health manifestos have long called for intersectoral action,89 and it is a central tenet of the UN’s sustainable development goals. Nonetheless, progress on climate-health intersectoral action has been meagre despite recognition of their shared determinants.101112

The scale and magnitude of the challenges facing humanity in the Anthropocene epoch provide a new imperative for intersectoral action on climate and health. The literature offers many lessons on the mechanisms and conditions under which intersectoral action is effective, often describing its barriers and facilitators. We argue that the key to making climate-health intersectoral action work, hinges on thinking politically about it (box 2).

Box 2

Thinking politically about intersectoral action—the “three I’s”

In considering intersectoral action it is important to ascertain the underlying distribution and exercise of power by those involved. Hence, the extent to which intersectoral action facilitators can be realised and barriers overcome depends on the associated political dynamics (who gets what, when, and how13). This is reflected in the policies and policy environments associated with intersectoral action, and these are influenced by the three I’s1415:

  • Ideologies—ideas, values. and beliefs that influence political positions and the framing employed to inspire action

  • Interests—incentives facing stakeholders to engage on specific issues and the power they wield as well as the commitment with which those interests are pursued

  • Institutions—structural factors that shape the rules governing policy processes


Barriers and facilitators to intersectoral action

Health (and illness) results from actions taken by individuals, communities, corporations, and governments within and, crucially, outside the health sector. The same logic applies to planetary health16 with health, business, and environment literature reporting similar barriers to, and facilitators of, intersectoral action.171819202122 We conducted a pragmatic review, grouping the wide variety of barriers and opportunities described into seven themes (box 3). Table 1 gives a purposefully selected set of case studies, showing these facilitators and barriers at different levels in diverse geographical settings.

Box 3

Barriers and facilitators of intersectoral action


  • Lack of political support

  • Inadequate leadership and links across sectors

  • Organisational and institutional constraints


  • Executive leadership

  • Shared cross sectoral goals and coordination

  • Civic mobilisation

  • Accountability

Table 1

Examples of intersectoral action programmes and how they are facilitated*

View this table:

Applying a political lens to barriers

Lack of political support

The lack of political support to impose shared cross sectoral goals across fragmented bureaucratic structures is a substantial constraint to intersectoral action. A signal that those in authority value such action is needed to establish the policies, financing, and structures to facilitate and incentivise collaboration; put the right people in boundary spanning posts; and to ensure accountability mechanisms to drive, chart, and correct progress.

The long timeframes and complexity involved can dissuade leaders from spending political capital on intersectoral action. When intersectoral action would entail confrontation with commercial interests, power imbalances between private and public sectors can lead to political apathy. And even if there are attempts to address these imbalances to overcome such apathy (as in the case of Thailand’s National Health Commission and Assembly, which attempted to do so by involving all key stakeholders, table 1), policy makers will often remain cautious in tackling vested commercial interests. Despite the centrality of politics to the success of intersectoral action, a review of the governance supporting a health in all policies approach found “significant naiveté when it comes to the politics and power games and the role that the health sector can or should play.”38 The same is true in the environment sector. For example, an analysis of intersectoral action to stop deforestation concludes that it takes civil society activism to apply pressure on decision makers to take the lead on intersectoral action.39

Inadequate leadership and links across sectors

A core leadership function of government is to promote the public good and mitigate public harm, particularly through regulatory and fiscal measures. With the imbalance of economic power between government and industry (corporations rather than states now comprise most of the world’s 100 largest revenue generators),40 leadership for effective regulation to address critical public issues across multiple sectors is increasingly challenging and inadequate.

Lack of leadership on the intersectoral action agenda reflects competing interests and ideologies and weak links across these. Scientific evidence on topics from tobacco to climate change has been undermined by vested interests sowing doubt to weaken the case for action.41 In the health sector, perhaps the most important barrier is that many people in leadership positions have a biomedical focus and either do not appreciate the critical role of the political and social determinants of health or are overwhelmed by unfamiliar challenges.42 For some, leadership on intersectoral action would mean establishing new relationships outside their comfort zones. Others may view intersectoral action as a threat to their authority or resources–affecting their interests and hence incentives for collaboration. The City Blueprint Approach to improve water management in Ahmedabad, India, reflects reluctance to meaningfully engage dissenting or critical voices, with a review noting that when solutions are needed quickly, “governmental agencies perceive stakeholder consultation a bit like an obstacle that slows down the city’s rapid development” (table 1).35

Organisational and institutional constraints

These barriers to intersectoral action stem partly from organisational cultures and disciplinary training. Narrow specialisation may not value collaboration and cooperation nor foster mindsets and skillsets amenable to working with other sectors, as well as encouraging inaccessible, specialist language. These weaknesses might result in a failure to consider incentives and goals pursued by other sectors, which is essential for sustainable collaboration. In the case of cooperation on health in all policies, it has been argued that “starting with the health argument may be counterproductive or politically inappropriate.”38 There is also institutional inertia that hinders organisations established with a limited set of goals from pivoting to embrace shared goals. So, while organisational cultures remain more likely to lead to rivalry than a spirit of cooperation for intersectoral action, leaders who have collaborative tendencies may find themselves on the periphery of policy making.38

Applying a political lens to facilitators

Executive leadership

Executive leadership (that is, leadership that transcends ministries, sectors, or departments), exercised at all levels, is a critical facilitator. Such leadership creates the ultimate political will for sectors to cooperate in that it is authoritative, can shape mandates, and demand compliance. The exercise of that leadership can take many forms, including altering the incentive structures of those who might otherwise pursue narrow sectoral goals; appointing boundary spanning staff (with contacts in and understanding of the culture of both organisations) to positions of authority; and establishing institutional arrangements and environments across government that facilitate intersectoral action.

Executive leadership is uniquely placed to provide intersectoral action on finance and cross sector budgets, as well as the mechanisms to hold ministries and other organisations accountable. By virtue of their positions, executives can often see the bigger picture, including overarching goals that transcend sectors, and define narratives that speak to shared values and inspire those around them to action.

What creates and sustains such leadership varies according to context; it might be a response to international commitments, a new economic imperative, carefully crafted narratives from advocates, or political demands from specific constituencies.

Shared cross sectoral goals and coordination

Structural mechanisms established by governments for coordination across ministries through joint committees, shared workplans, and pooled budgets are crucial to intersectoral action, as exemplified in the health in all policy approaches. From a political perspective, the success of these initiatives depends on acknowledging and accommodating diverse and sometimes competing interests. “Soft” elements are also important, including the creation of organisational cultures and ideologies that reward such efforts, providing incentives, and building informal networks across ministries to foster shared values and trust. They tend to rely on a leadership style, interpersonal behaviour traits, and skill sets such as persuasion, nudging, negotiation, conflict resolution, and trust building.

Civic mobilisation

Changing behaviour for human and planetary health requires interaction between the public (both as citizens and consumers), policy makers, and private sector leaders. Governments have an obligation to serve public interests, including protection against commercial interests, but this often requires “bottom-up” demand. The Montreal protocol on ozone depleting compounds provides a good example of the science community providing compelling evidence around which to mobilise and foster commitment to change (table 1).4344 Citizens have an important role in demanding change or more ambitious action45 through consumer choices, civil society organisations, and social movements (for example, driving the introduction of nature based planning in Sweden, table 1). They can also be a powerful voice demanding urgent and coordinated action across government, as shown by the activism of the AIDS movement (table 1).


Robust governance and accountability mechanisms are a prerequisite for intersectoral action as they document responsibility for actions. Legislation in support of intersectoral action, often in response to political mobilisation, can have a similar effect as it draws on established mechanisms in government to ensure accountability, and moreover can have a lasting effect beyond any particular administration. Examples include the Public Health Act in South Australia and the mandate for health equity in Scandinavian municipality budgets.4647

Poorly conceived intersectoral action can lead to blurred lines of accountability. This can be mitigated with clear goals, an explicit division of labour, and integrated accountability wherein the contributions of different sectors are considered holistically. Independent review by people who are not directly involved in policy or implementation can identify barriers such as vested interests as well as shared goals and lessons. The UN secretary general’s independent accountability panel for the Every Woman Every Child project shows the success of this approach (box 4). Community groups with lived experience or advocacy groups can also provide accountability by applying pressure to ensure intersectoral action.

Box 4

UN independent accountability panel: a model for intersectoral action

  • The UN secretary general mandated the formation of the independent accountability panel for the Every Woman, Every Child, Every Adolescent (EWEC) initiative in 201648

  • The group of experts evaluated 10 years of work in the EWEC movement and evolved its accountability framework. In the process, they consulted widely, gathered, and evaluated evidence and listened to people’s experiences of accountability for their health and rights

  • In the resulting report the panel sets out an accountability framework for health across the sustainable development goals (SDGs)

  • The overarching recommendation is to move towards holistic, people centred accountability by meaningfully engaging all major SDG groups and other stakeholders at regional, country and global levels, and institutionalising an independent review mechanism for intersectoral action on health across the SDGs

  • The framework provides a coherent, evidence based tool that any country or organisation can use to inform its accountability


Going forward

The facilitators of intersectoral action seem to be synergistic. From a political perspective, leadership on intersectoral action would be more forthcoming if there were demands from civil society, as exemplified by the Montreal protocol. And sectoral leadership would be more responsive to intersectoral action if inspired by the vision of what it can deliver, transcending the insular mantras and priorities of any individual sector.

Compelling narratives are also key to mobilising politicians and the public. The independent accountability panel suggests that putting people, as opposed to economic growth, at the centre of policy can help secure support. Those vested in human health and planetary health share the fundamental value of tackling inequality, which ought to provide common ground to foster collaboration.

From the top, a more systematic approach with clearer articulation of which ministries should initiate and lead on different intersectoral action on climate and health issues is critical, not least so that the relevant people can be held accountable, including by civil society. Nonetheless, if intersectoral action is to be effective in different contexts, global concepts such as net zero and forest loss need to be translated to local situations with context specific solutions. And for sustained climate-health intersectoral action it will be critical that the current demands are channelled into legislation. Litigation can help to advance mitigation action, and about 1000 cases have been brought worldwide between 2015 and 2021.49

Well designed and implemented carbon pricing and subsidy removal can accelerate intersectoral action by redirecting resources to actions that improve health equity as well as cutting greenhouse gas emissions.50 Health indicators should be integrated into reporting of efforts to reduce emissions and build resilience to climate change as well as fostering planetary health more widely.

To date, political dynamics have served as barriers to intersectoral action. Yet there are grounds for optimism. The Human Rights Council recently recognised the right to a healthy environment,51 which may lead to greater attention, new legislation, and litigation on climate-health intersectoral action. The activism of climate campaigners provides further reasons for hope. It may newly politicise public health, which has grown away from its overtly political roots,52 and thus encourage intersectoral action. It may also confront the shared commercial determinants of illness and environmental degradation by demanding more effective regulation. At the same time, public health should aim to diminish political polarisation by focusing on common aspirations for a healthy and sustainable future that can command widespread support.

Divisions are emerging within the private sector between those that see their future business model tied to a more sustainable economy and those who base their future on opposing change, with a large middle group that could lean in either direction depending on consumer demand and regulatory pressures. The challenge is to strengthen those focused on a more sustainable economy and influence the undecided by calling out attempts at “greenwashing.” Accountability for progress on climate-health intersectoral action ought ultimately to be to the electorate, not shareholders, although shareholders could have a positive role. Substantial investment is required in informing and engaging the public on tracking commitments made by governments and corporations, as well as in independent verification.

Linking climate-health intersectoral action to existing political processes holds considerable promise. One opportunity lies in the development of the UN Framework Convention on Climate Change, building on work on health in the nationally determined contributions to climate action under the Paris agreement.53 Another opportunity lies in the review process of the sustainable development goals, which spans from local up to a high level political forum.54 Building on the lessons from the UN secretary general’s independent accountability panel, establishing an independent review mechanism to report on climate-health intersectoral action to the forum could provide the structure to drive progress.

The climate emergency provides renewed impetus to motivate political leaders to capitalise on the opportunities for climate-health intersectoral action. The sooner we act politically on the facilitators and barriers to intersectoral action, the closer humanity will be to realising the right to a healthy environment and the goals of sustainable development.

Key messages

  • Emphasising the co-benefits to health of actions to counter environmental change in other sectors could help to motivate more ambitious intersectoral action

  • Intersectoral action is beset by political challenges, as evidenced by the watered down commitments that emerged from the COP26 summit in Glasgow

  • Barriers to intersectoral action include outdated institutions, the influence of vested interests, and limited ability of evidence and technocratic approaches to shift the political dial

  • Enablers include political demands arising from social movements that are pressuring governments to confront climate breakdown and its impacts on human health

  • The key to unlocking the potential for intersectoral action will be visionary leaders defining ambitious, long term shared goals that motivate civil society action, and independent monitoring


  • Contributors and sources: This article builds on a webinar chaired by GT and hosted by the George Institute for Global Health in May 2021 on the intersectoral action needed for the future health of people and planet, at which AH gave the keynote speech. SK, JM, and OPO contributed insights and case studies to the panel discussion from multilateral, country, and health systems experiences, respectively. KB led the framing and drafting of the article. In addition to project management, AA and MvdM’s experience in communications and engagement further strengthened the messaging.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: KB has received grants or contracts from WHO and the Bill and Melinda Gates Foundation; SK was co-chair of the BMJ 2018 series on making multisectoral collaboration work; AH is principal investigator of the Pathfinder Initiative funded by Wellcome (grant number 221284/Z/20/Z) with support from the Oak Foundation (grant number OFIL-20-093). He is co-investigator on the Complex Urban Systems for Sustainability and Health (CUSSH) project, which is supported by Wellcome [209387] Trust and on the Sustainable Healthy Food Systems project supported by the Wellcome Trust [205200].  He also received part time salary support to his institution as Wellcome Trust adviser on climate change and health (March-October 2021).

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • This article is part of a series commissioned for the Prince Mahidol Awards Conference (PMAC) in January 2022. Funding for the articles, including open access fees, was provided by PMAC. The BMJ commissioned, peer reviewed, edited, and made the decision to publish these articles. Rachael Hinton and Kamran Abbasi were the lead editors for The BMJ.

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