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

Reconceptualising the commercial determinants of health: bringing institutions in

The concept of the 'commercial determinants of health' (CDOH) has been developed by public health researchers as a way to describe the political economy of corporations and the impact of their practices on health, social inequalities and climate change. In this analysis, we assess the conceptual work that has developed this field and the influence of the more established 'social determinants of health' models. We highlight the dominance of epidemiologic and biomedical concepts on understandings of structure and agency in the CDOH literature and argue that the terminology of 'risk factors', 'drivers' and 'pathways' reflects an agent-centred approach. We suggest that, as a result, there is a tendency to overlook the importance of political institutions in shaping the exercise of corporate power. Our analysis seeks to 'bring institutions in' to CDOH research, using the empirical cases of Health in All Policies and Better Regulation in the European Union to highlight how institutional contexts shape political legitimacy and accountability, and in turn the strategies of corporate actors. Institutionalist approaches, we argue, have the potential to develop and expand understandings of CDOH by opening the black box between agency and structure.

How can policy and policymaking foster climate justice? A qualitative systematic review

Background

Climate change research has established general requirements for policy and policymaking: transformational changes in policy and policymaking to foster 'climate justice', including a 'just transition' or movement towards environmental sustainability with equitable processes and outcomes. However, there is a major gap between these requirements and actual policies and policy processes. We identify how researchers use policy theories to understand this gap.

Methods

We conducted a qualitative systematic review (2022) to identify peer reviewed journal articles on climate change, policy, justice, and equity in three databases (Web of Science, Scopus, Proquest). Each article had to provide a non-trivial reference to policymaking concepts or theories. We used an immersive and inductive approach to identify key themes and show how the use of policy concepts and theories informs climate change research.

Results

A total of 108 texts meet the inclusion criteria (with some bias towards Global North research since all texts are in English). Most provide general definitions of climate justice, require fair outcomes and processes, and list what is required to meet those aims. However, they also identify unjust processes and outcomes in relation to who is recognised, gets to define the problem, and wins or loses from solutions. Researchers contrast their preferred social justice approach (informing 'civic environmentalism) to a dominant neoliberal approach (corresponding to weak 'ecological modernization').

Conclusions

Researchers focus on what they need from policy and policymaking to produce climate justice. Few engage meaningfully with policy theories to describe how policymaking actually works. More engagement would help to set meaningful expectations regarding policy change and avoid a needless tendency to treat policymaking like a 'black box'.

"Health in All Policies" in Norwegian municipalities-Dilemmas and lack of legitimacy and capacity

According to the Health in All Policies (HiAP) approach, public health work in Norway is regarded as a multi-actor collaboration based on planning and partnership for the purpose of enabling people to increase their control over their health and its determinants. HiAP builds largely on the governance and communicative turn in the public sector and thus exists in the shadow of a vertical government structure with sectors, silos and a chain of command. In practice, HiAP challenges the established way of thinking and acting in the silos and tries to create a more holistic understanding and handling of problems and needs. In order to successfully involve different sectors and government levels in this work, HiAP requires strong democratic legitimacy and institutional capacity. In this article, we discuss the empirical research data on the HiAP approach in Norway within the context of theory on collaborative planning processes and legitimising political capacity to act. Our research question is whether the HiAP approach in Norwegian municipalities have sufficient democratic legitimacy and institutional capacity to achieve the purpose of public health work. In general, we find that HIAP as practised in Norwegian municipalities does not function as a complete political legitimising and capacity building process. The practice contains several dilemmas, and there is a need to distinguish between different forms of legitimacy and capacity.

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.

Policy design for territorial equity in multi-level and multi-sectoral political systems: Comparing health and education strategies

The EU has many plans to foster equity and spatial justice. However, each has separate reference points, and it is difficult to find an overall vision. To demonstrate, we analyse two sectoral strategies to identify their implications for spatial justice strategies. Education focuses on early investment and public service reform. Health prioritises intersectoral action to address the 'social determinants' beyond the control of health services. Both warn against equating territorial cohesion or spatial justice with equal access to public services. These findings could inform European Commission strategy, but it tends to respond with renewed rhetoric rather than reconsidering its approach.

Evaluating ‘Health in All Policies’ in Norwegian Municipalities

The Health in All Policies (HiAP) approach has emerged as a central strategy for promoting health at local, regional, and state levels in different countries. Representing a complex and complicated strategy, evaluations of HIAP at the local level are scarce, and scholars call for more knowledge and critical discussions regarding how to evaluate at this level. In this conceptual paper, I discuss how summative and formative evaluation approaches might supplement each other when evaluating HiAP at the local level. First, I discuss the possibilities of using summative and formative evaluation of HiAP. Further, I discuss how formative-dialogue research might represent possibilities for evaluation by combining the two approaches. Finally, I ask if there has been a shift in the Norwegian evaluation discourse, from the promotion of summative evaluation alone to a combination of both summative and formative methods.

The future of education equity policy in a COVID-19 world: a qualitative systematic review of lessons from education policymaking

Background: COVID-19 had a major global impact on education, prompting concerns about its unequal effects and some impetus to reboot equity strategies. Yet, policy processes exhibit major gaps between such expectations and outcomes, and similar inequalities endured for decades before the pandemic. Our objective is to establish how education researchers, drawing on policy concepts and theories, explain and seek to address this problem. Methods: A qualitative systematic review (2020-21), to identify peer reviewed research and commentary articles on education, equity, and policymaking, in specialist and general databases (ERIC, Web of Science, Scopus, Cochrane/ Social Systems Evidence). We did not apply additional quality measures. We used an immersive and inductive approach to identify key themes. We use these texts to produce a general narrative and explore how policy theory articles inform it. Results: 140 texts (109 articles included; 31 texts snowballed) provide a non-trivial reference to policymaking. Limiting inclusion to English-language produced a bias towards Global North articles. Our comparison with a review of health equity research highlights distinctive elements in education. First, education equity is ambiguous and contested, with no settled global definition or agenda (although some countries and international organisations have disproportionate influence). Second, researchers critique 'neoliberal' approaches that dominate policymaking at the expense of 'social justice'. Third, more studies provide 'bottom-up' analysis of 'implementation gaps'. Fourth, more studies relate inequity to ineffective policymaking to address marginalised groups. Conclusions: Few studies use policy theories to explain policymaking, but there is an education-specific literature performing a similar role. Compared to health research, there is more use of critical policy analysis to reflect on power and less focus on technical design issues. There is high certainty that current neoliberal policies are failing, but low certainty about how to challenge them successfully.

The future of education equity policy in a COVID-19 world: a qualitative systematic review of lessons from education policymaking

Background: COVID-19 had a major global impact on education, prompting concerns about its unequal effects and some impetus to reboot equity strategies. Yet, policy processes exhibit major gaps between such expectations and outcomes, and similar inequalities endured for decades before the pandemic. Our objective is to establish how education researchers, drawing on policy concepts and theories, explain and seek to address this problem. Methods: A qualitative systematic review (2020-21), to identify peer reviewed research and commentary articles on education, equity, and policymaking, in specialist and general databases (ERIC, Web of Science, Scopus, Cochrane/ Social Systems Evidence). We did not apply additional quality measures. We used an immersive and inductive approach to identify key themes. We use these texts to produce a general narrative and explore how policy theory articles inform it. Results: 140 texts (109 articles included; 31 texts snowballed) provide a non-trivial reference to policymaking. Limiting inclusion to English-language produced a bias towards Global North articles. Our comparison with a review of health equity research highlights distinctive elements in education. First, education equity is ambiguous and contested, with no settled global definition or agenda (although some countries and international organisations have disproportionate influence). Second, researchers critique 'neoliberal' approaches that dominate policymaking at the expense of 'social justice'. Third, more studies provide 'bottom-up' analysis of 'implementation gaps'. Fourth, more studies relate inequity to ineffective policymaking to address marginalised groups. Conclusions: Few studies use policy theories to explain policymaking, but there is an education-specific literature performing a similar role. Compared to health research, there is more use of critical policy analysis to reflect on power and less focus on technical design issues. There is high certainty that current neoliberal policies are failing, but low certainty about how to challenge them successfully.

Lessons Learnt from the EU Response to NCDs: A Content Analysis on Building Resilient Post-COVID Health Systems

Non-communicable diseases (NCDs) impose a heavy burden on the healthcare system of countries in the European Union (EU). An estimated 91.3% of all deaths and 86.6% of DALYs in the EU-28 were attributable to NCDs. It is imperative that the EU act on mitigating this challenging health issue and help create trajectories for building resilient health systems. Using qualitative analysis, this study examines the question of how the European Commission 2019-2024 is planning to mitigate the impact of NCDs on health systems, while taking into account the COVID-19 pandemic. A content analysis of 44 documents communicating the European Commission's position on the issue was done. In vivo coding was performed using the software package ATLAS.ti 9. Unique codes were simplified and grouped into main themes. Five main themes were identified: 'health plan', 'COVID-19', 'future direction', 'collaboration and solidarity', and 'persuasion'. This study shows that the European Commission is emphasising the impact of the pandemic and the relevance of policies tackling NCDs. By calling for more cross- and multi-sectoral collaboration, the Commission hopes to create the right climate for a European framework for cooperation, which can help develop EU-wide resilient health systems.

'Health in All Policies'-A Key Driver for Health and Well-Being in a Post-COVID-19 Pandemic World

Policy in all sectors affects health, through multiple pathways and determinants. Health in all policies (HiAP) is an approach that seeks to identify and influence the health and equity impacts of policy decisions, to enhance health benefits and avoid harm. This usually involves the use of health impact assessment or health lens analysis. There is growing international experience in these approaches, and some countries have cross-sectoral governance structures that prioritize the assessment of the policies that are most likely to affect health. The fundamental elements of HiAP are inter-sectoral collaboration, policy influence, and holistic consideration of the range of health determinants affected by a policy area or proposal. HiAP requires public health professionals to invest time to build partnerships and engage meaningfully with the sectors affecting the social determinants of health and health equity. With commitment, political will and tools such as the health impact assessment, it provides a powerful approach to integrated policymaking that promotes health, well-being, and equity. The COVID-19 pandemic has raised the profile of public health and highlighted the links between health and other policy areas. This paper describes the rationale for, and principles underpinning, HiAP mechanisms, including HIA, experiences, challenges and opportunities for the future.