Creating a whole-of-government approach to promoting healthy weight: What can Health in All Policies contribute?

Can health impact assessment help tackle commercial determinants of health and support a wellbeing economy?

Commercial activity has positive and negative effects on health. Adverse commercial impacts on health are underpinned by corporate power and economic models and policy that prioritize economic growth, rather than a wellbeing economy that prioritizes health, equity and sustainability. Health in all policies (HiAP) aims to ensure that all policies promote health and health equity, using processes including health impact assessment (HIA). We aimed to explore the potential for HiAP and HIA to help address commercial determinants of health and promote a wellbeing economy. We completed a scoping review to identify how HiAP approaches, including HIA, could address commercial determinants, including challenges and implications for practice. This found synergy between the concepts of wellbeing economy and HiAP. However, corporate interests have sometimes co-opted HiAP to influence policy. We found some examples of HIAs of transnational corporations and international trade and investment agreements. We reviewed HIA frameworks for guidance to practitioners on managing corporate influence. This identified little guidance on identifying and managing corporate and other conflicts of interest or managing power differentials between stakeholders. We also mapped wellbeing economy outcomes against health determinants considered in selected HIA frameworks. This found that HIA frameworks with a comprehensive checklist of health determinants prompt consideration of most wellbeing economy outcomes. HIA could support the transition to a wellbeing economy if applied routinely to economic policies, but ideational change is also needed. HIA frameworks should provide guidance on corporate conflicts of interest and power differentials.

Tools for local health in all policies implementation: evidence from an explanatory case study of Kuopio, Finland

AIMS

This paper describes the use of three governance tools for health in all policies utilised to facilitate implementation in the municipality of Kuopio, Finland: impact assessments, a city mandate (the Kuopio strategy), and shared budgets.

METHODS

An explanatory case study was used. Data sources included semistructured interviews with 10 government employees and scholarly literature. Realist scientific methods were used to reveal mechanisms underlying the use of tools in health in all policies.

RESULTS

Strong evidence was found supporting initial and new theory/hypotheses regarding the use of each tool in achieving positive implementation outcomes. Impact assessments facilitated health in all policies by enhancing understanding of health implications. The Kuopio strategy aided in implementation by giving credence to health in all policies work via formal authority. Shared budgets promoted intersectoral discussions and understanding, and a sense of ownership, in addition to allowing time to be spent on health in all policies work and not financial deliberation.

CONCLUSIONS

Findings confirm the efficacious use of three governance tools in implementing health in all policies in Kuopio. Knowledge and evidence-based guidelines on local health in all policies implementation are needed as this policy approach continues to be recognised and adopted as a means to promote population health and health equity.

Governance of Intersectoral Collaborations for Population Health and to Reduce Health Inequalities in High-Income Countries: A Complexity-Informed Systematic Review

BACKGROUND

A 'Health in All Policies' (HiAP) approach has been widely advocated as a way to involve multiple government sectors in addressing health inequalities, but implementation attempts have not always produced the expected results. Explaining how HiAP-style collaborations have been governed may offer insights into how to improve population health and reduce health inequalities.

METHODS

Theoretically focused systematic review. Synthesis of evidence from evaluative studies into a causal logic model.

RESULTS

Thirty-one publications based on 40 case studies from nine high-income countries were included. Intersectoral collaborations for population health and equity were multi-component and multi-dimensional with collaborative activity spanning policy, strategy, service design and service delivery. Governance of intersectoral collaboration included structural and relational components. Both internal and external legitimacy and credibility delivered collaborative power, which in turn enabled intersectoral collaboration. Internal legitimacy was driven by multiple structural elements and processes. Many of these were instrumental in developing (often-fragile) relational trust. Internal credibility was supported by multi-level collaborations that were adequately resourced and shared power. External legitimacy and credibility was created through meaningful community engagement, leadership that championed collaborations and the identification of 'win-win' strategies. External factors such as economic shocks and short political cycles reduced collaborative power.

CONCLUSION

This novel review, using systems thinking and causal loop representations, offers insights into how collaborations can generate internal and external legitimacy and credibility. This offers promise for future collaborative activity for population health and equity; it presents a clearer picture of what structural and relational components and dynamics collaborative partners can focus on when planning and implementing HiAP initiatives. The limits of the literature base, however, does not make it possible to identify if or how this might deliver improved population health or health equity.

A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland

BACKGROUND

Health in All Policies (HiAP) encompasses collaboration across government and the consideration of health in various governmental sector's policies and decisions. Despite increasing advocacy, interest, and uptake in HiAP globally, empirical and evaluative studies are underrepresented in this growing literature, particularly literature on HiAP implementation at the local level. Finland has been a pioneer in and champion for HiAP.

METHODS

A realist explanatory case study design was used to test hypotheses about how HiAP is implemented in Kuopio, Finland. Semi-structured interviews with ten government employees from various sectors were conducted. Data from interviews and literature were analyzed with the aims of uncovering explanatory mechanisms in the form of context-strategy-mechanism-outcome (CSMO) configurations related to implementation strategies. Evidence was evaluated for quality based on triangulation of sources and strength of evidence. We hypothesized that having or creating a common goal between sectors and having committed staff and local leadership would facilitate implementation.

RESULTS

Strong evidence supports our hypothesis that having or creating a common goal can aid in positive implementation outcomes at the local level. Common goals can be created by the strategies of having a city mandate, engaging in cross-sectoral discussions, and/or by working together. Policy and political elite leadership led to HiAP implementation success because leaders supported HiAP work, thus providing justification for using time to work intersectorally. How and why the wellbeing committee facilitated implementation included by providing opportunities for discussion and learning, which led to understanding of how non-health decisions impact community wellbeing, and by acting as a conduit for the communication of wellbeing goals to government employees.

CONCLUSION

At the municipal level, having or creating a common goal, leadership from policy and political elites, and the presence of committed staff can facilitate HiAP implementation. Inclusion of not only strategies for HiAP, but also the explanatory mechanisms, aids in elucidating how and why HiAP is successfully implemented in a local setting.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

Recent Advances in Health Impact Assessment and Health in All Policies Implementation: Lessons from an International Convening in Barcelona

Health Impact Assessment (HIA) and Health in All Policies (HiAP) are policy tools used to include health considerations in decision-making processes across sectors such as transportation, education, and criminal justice that can play a role in improving health and equity. This article summarizes proceedings from an international convening of HIA and HiAP experts held in July 2019 in Barcelona, Spain. The presentations and panel discussions included different models, best practices, and lessons learned, including from government, international banks, think tanks, and academia. Participants discussed ideas from around the world for cross-sector collaboration to advance health. The convening covered the following topics: community engagement, building greater understanding of and support for HiAP, and exploring how mandates for HIA and HiAP approaches may advance health and equity.