Challenges of inter-sector collaboration in public policies: the dilemma between nutritional supplementation and the promotion of healthy eating in schools

Abstract: The study aimed to identify and analyze the development of inter-sector arrangements between the health and education sectors in the framework of the implementation of the NutriSUS strategy in a municipality (county) in the state of Rio de Janeiro, Brazil. The study was conducted from March 2015 to March 2017 and used policy analysis as the analytical reference, with the following analytical dimensions: operational design; ideas on the nutritional supplementation; institutional context; and inter-sector collaboration. Semi-structured interviews were held with health professionals and administrators and schoolteachers and school system administrators at the three levels of government, in addition to document analysis. The NutriSUS strategy was implemented in five preschool units and required establishing agreements between health professionals and teachers that were affected by the following: the design based on the preventive approach to diseases with emphasis on action by the health sector; mechanisms of induction and convergence of interests between the federal and local governments; management mechanisms and institutional spaces including different stages in the implementation process, that is, the NutriSUS management centered in the health sector but operationalized in the school system; and the intersection between NutriSUS and the National School Food Program which increased the visibility of competing concepts concerning supplementation as a preventive strategy and different approaches to promote healthy eating. Thus, the factors identified by the study challenge the development of inter-sector collaboration oriented by shared processes in the entire chain of implementation of inter-sector programs for schools.

摘要：本研究旨在识别并分析巴西里约热内卢州某自治县在实施营养健康系统（NutriSUS）战略的框架下，卫生与教育部门间跨部门协作安排的发展演进情况。本研究于2015年3月至2017年3月开展，以政策分析为分析框架，设定四大分析维度：运行设计、营养补充相关理念、制度背景及跨部门协作。研究除开展文献分析外，还对三级政府体系内的卫生专业人员、行政管理人员、学校教师及学校系统管理者进行了半结构化访谈。

营养健康系统（NutriSUS）战略在5所学前教育机构落地实施，该战略要求卫生专业人员与教师建立协作共识，而这一协作进程受到以下因素影响：以疾病预防为导向、侧重卫生部门履职的方案设计；联邦与地方政府间的利益诱导与趋同机制；涵盖实施全流程各阶段的管理机制与制度空间——即营养健康系统（NutriSUS）的管理主体为卫生部门，但实际运行依托学校系统；以及营养健康系统（NutriSUS）与全国学校供餐计划（National School Food Program）的交叉融合，这一交叉使得作为疾病预防策略的营养补充相关竞争性理念，与促进健康饮食的不同实施路径的受关注度均有所提升。

综上，本研究识别出的各类因素，对面向学校的跨部门项目全实施链条中，以共享流程为导向的跨部门协作发展构成了挑战。