8. Boosting cross-sector work through coaching in the Netherlands



Recognising that cross-sector collaboration is critical for tackling issues like obesity, a Dutch public health service developed a coaching programme to help public health staff engage colleagues in other sectors and develop health in all policies approaches.





South Limburg regional public health service launches a ‘health in all policies’ coaching programme to upskill local public health staff in facilitating cross-sector collaboration to improve health locally.


Local and regional public health specialists participate in action learning sets, meeting seven times over 30 months.


South Limburg regional public health service evaluates the programme in partnership with Maastricht University’s Care and Public Health Research Institute and the Academic Collaborative Centre for Public Health Limburg.


Evaluation is published.


The Netherlands is divided into 12 provinces, which have devolved responsibility for policy areas such as health, spatial planning and recreation.

At the local level there are 418 municipalities. Each has a council that is responsible for developing and implementing local health policy. Each council is governed by a mayor (appointed by the national government) and aldermen (appointed by the councillors who, in turn, are publicly elected). This structure has important implications: since councillors are publicly elected, they tend to prioritise policies that deliver visible results within their four-year electoral term. This is one reason why complex health issues such as obesity have historically been neglected.

Each municipal council has local public health staff and jointly funds a regional public health service, which supports it to develop and implement its health policy.

The intervention

South Limburg is a former mining region in southern Netherlands. Today its population experiences high unemployment and poor health, including some of the highest obesity rates in the country.

In 2007, South Limburg’s regional public health service secured research funding to explore new ways of facilitating health in all policies. It developed a coaching programme to upskill public health staff working in local municipalities to facilitate cross-sector collaboration and develop approaches to tackling obesity through non-health sector action.

The programme sought to develop participants’ skills in two ways. It boosted ‘vertical’ collaboration, between public health colleagues working in strategic, tactical and operational roles. Importantly, it also enabled ‘horizontal’ collaboration between public health specialists and their counterparts in other sectors, including welfare, sports and recreation, youth and education, transport, planning and social affairs.

Managers in local municipalities were sent information about the programme and the importance of cross-sector collaboration for improving health, and were asked to allow their staff to spend at least two hours a week on the programme. This request came via local councillors and staff. The regional public health team running the programme did not directly engage with the managers.

Nine local municipalities volunteered to take part in the programme. The activities included:

  • three conferences for elected councillors to reinforce their role as health leaders and to get their support for using a health in all policies approach and driving cross-sector collaboration on obesity
  • a masterclass to train local and regional public health staff in stimulating cross-sector collaboration on obesity, such as through using health impact assessments
  • multiple action learning sets involving a local municipality civil servant, a public health specialist from the regional public health service and a health promotion specialist. Each trio met over a 30-month period to develop cross-sectoral action plans on obesity. Outside the learning sets, the participants met local councillors and experts to discuss how cross-sector collaborations might help tackle obesity locally.


The coaching programme was evaluated through a combination of before-and-after surveys, in-depth interviews and log books kept by the action learning set participants. All 32 of Limburg’s municipalities took part in the evaluation, which produced a range of findings.,

  • The civil servants who participated in the programme felt their self-efficacy increased over the 30-month period.
  • The municipalities that participated in the programme did so because of established relationships with the regional public health service. These made them more open to trialling the new approach.
  • Overall, the programme failed to embed a comprehensive and sustainable health in all policies approach in the participating municipalities. However, six of the nine participating areas developed relatively narrow cross-sectoral proposals to tackle obesity. For example, one municipality introduced health impact assessments for spatial and environmental planning proposals, particularly focusing on obesity impacts.
  • Senior managers among non-participating municipalities said they did not feel the merits of cross-sector collaboration had been sufficiently well demonstrated to warrant increasing their teams’ already-stretched capacity.
  • Over the 30-month period, the managerial support for health in all policies decreased among the participating municipalities. This may have been due to competing priorities, high staff turnover and a lack of evidence of success. This led to coached civil servants feeling they had no authority to change their practice and influence others, which was a barrier to the programme’s success.
  • High staff turnover meant the knowledge gained from the programme was quickly lost and, with it, the programme’s momentum. Similar turnover at leadership level impacted on senior commitment to health in all policies, which fell during the course of the programme.

Lessons learned

What worked well

  • The civil servants who took part felt their self-efficacy had increased by the end of the programme, which suggests the training helped them develop personally and professionally. However, this did not translate into large-scale organisational change and collaborations.

What worked less well

  • High staff turnover contributed to the programme’s failure to embed health in all policies in the municipalities. The programme may have had greater success had it addressed how to embed the approach more formally into organisations’ ways of working, to remove the reliance on key individuals.
  • A lack of managerial buy-in limited the programme’s success. Future efforts to embed health in all policies should ensure managers are engaged throughout, as they have the power to set priorities, allocate resources and empower their staff. Managers may also be incentivised to support the approach by giving them roles and responsibilities around cross-sector working, such as empowering and supporting staff to consider health in all policies, and developing their own relationships with colleagues in other policy areas.
  • Of the 18 South Limburg municipalities invited to participate in the programme, only nine took up the offer. Participation was due to strong personal relationships with the regional public health service, rather than because individuals felt persuaded by the topic or approach.
  • At the time that the programme was introduced, municipalities were focusing on other priorities, such as unemployment. Framing the programme in health language (using terms such as ‘obesity’), meant that many staff struggled to understand how it would benefit them. Also, some may have perceived the obesity topic as relating to individual behaviour change approaches. These can be politically controversial as they can be seen as interfering with people’s private lives.
  • The framing may have chimed better with other municipalities and non-health departments if, instead, it had focused on more universal policies, such as influencing the physical environment or outcomes such as quality of life or social inclusion.
  • Improving the participants’ influencing skills – including the ability to reframe arguments and tailor arguments to the audience – may have helped them persuade leaders and colleagues of the need to take a cross-sector approach to improve health. For example, participants may have had more success by presenting politicians with simple, clear arguments that related to their political priorities, while sharing more detailed, technical information about causes and solutions with other civil servants.

In addition, explicitly agreeing on and setting clear health targets at the outset, and developing a shared plan for how to achieve them, might have stimulated stronger collaboration.

Implications for the UK

Many local public health teams are already promoting health in all policies and building cross-departmental partnerships to improve health through the social determinants. This case study offers some interesting ideas about how to improve public health professionals’ skills and confidence in facilitating cross-sector collaboration through training and action learning.

However, coaching programmes should be designed to take account of, and address, power imbalances that might otherwise limit participants’ authority to act. In particular, middle managers should be recognised as key enablers of change and engaged fully in any organisational development process.

Framing problems and solutions in ways that resonate with all stakeholders is critical. Health issues such as obesity should be framed in ways that highlight their relevance to non-health actors and emphasise how collaboration will help all parties meet their goals.

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