Health Promotion International, Vol. 29 No. S1 doi:10.1093/heapro/dau051
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EDITORIAL
The Eighth Global Conference on Health Promotion: Health in All Policies: From Rhetoric to Action
THE HIAP ARGUMENT ‘We must remember health is an outcome of all policies’, United Nations (UN) Secretary General Ban Ki Moon said in his Statement to the 2009 World Health Assembly (UN, 2009). Similar claims have become increasingly commonplace, including the remark by the Director-General of the World Health Organization (WHO) Margaret Chan at the opening of the 8th Global Conference on Health Promotion: ‘The HiAP makes perfect sense. The determinants of health are exceptionally broad. Policies made in other sectors can have a profound, and often adverse, effect on health’ (WHO, 2013a). These claims are well established and based on evidence. The profound impact of all public
policies on health has been comprehensively mapped (Milio, 1981). To list a few examples of how health is impacted by policies beyond the health sector, death rates due to road traffic incidents have declined by over 60% in Australia, France, Sweden and UK over the past four decades (UN, 2010; Krug, 2013), as a result of a set of evidence-based practices including road engineering and motor vehicle safety measures. A reduction of 5 g of salt intake from 10 g per day reduces the rates of stroke by 23% and the overall rates of cardiovascular disease by 17% (Strazullo et al., 2009). Raising taxes on tobacco and alcohol has already saved and will continue to save thousands of lives. Detrimental policies beyond the health sector include poor occupational safety and health practices which lead to not only deaths and injuries but also economic losses up to 4– 5% of global gross domestic product each year (ILO, 2014). Action across sectors has also been proven essential to combating communicable diseases such as cholera centuries ago and like SARS more recently (Lai and Tan, 2012; Ching et al., 2013). These claims also build on the foresight of many public health pioneers including Linnaeus in Sweden in the 17th Century (Asp, 2007; Ra¨sa¨nen, 2007), Snow and Chadwick(Chadwick, 1842; Snow, 1855) in the mid-19th Century in the UK and by Winslow (Winslow, 1920) in the early 20th century in the USA. They all agreed on the need to address issues beyond personal hygiene and quality health care and to look at particularly living and working conditions (Rosen, 1993; Porter, 1997). HiAP application was also established as early as the 7th century in China when quarantine was a public health practice, detaining sailors and foreign travellers suffering from plague (WHO, 2007) (http://www.who.int/whr/ 2007/07_chap1_en.pdf ). i1
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Between 9 and 14 June 2013, some 650 expert participants from 122 countries met in the Finlandia Hall in Helsinki, Finland with one common goal: to advance the practical approaches for implementing the health-in-all-policies (HiAP) approach. This Supplement of the Journal presents core documents that were prepared before, during and after the Conference. Manuscripts were peer reviewed with the assistance and diligence of a Guest Editorial Board. The editors would like to take this opportunity to thank the members of the Conference Organizing and Scientific Committees for their contributions to achieving better health and health equity through application of HiAP and other actions across sectors, in particular, the production of the Helsinki Statement on Health in All Polices and the HiAP Framework for Country Action. A full list of the members is available at http://www. who.int/healthpromotion/conferences/8gchp/en/.
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Immediate action is warranted. The mandate is clear and the needs and opportunities are obvious. Rhetoric is easy, and we need to move towards tangible, concrete and replicable insights into how integrated policy responses to complex health issues come about. What is missing is the body of knowledge that maps determinants of policy effectiveness and the processes involved, what the building blocks are for putting health in all policies (HiAP) and how policy coherence for health promotion can be achieved, given that governments always have a range of priorities and health and its equity are not automatically at the top of the list. THE FOUNDATIONS OF THE EIGHTH GLOBAL CONFERENCE ON HEALTH PROMOTION The Finnish Government illustrated the importance of a HiAPs approach, given their long history for horizontal, comprehensive health policy. The roots of the Finnish Health in All Policies approach can be traced back to 1972 when the Economic Council of Finland (The Economic Council of Finland, chaired by the Prime Minister, is a body for facilitating cooperation between the government and major interest groups. It discusses economic and social issues that are of central importance to the success of the nation.) recognized the need for comprehensive health policy and set sector-specific health objectives outside health sector, e.g. to prevent road accidents and deaths (Economic Council, 1972). Since then, other government ministries have also discussed and developed policies which consider health. At the time when Finland joined the European Union in 1995 some power was given to European Union so that Finland did not have any more complete control over its health policy, e.g. restricting travellers’ alcohol and cigarette quotas from abroad—in Finland the alcohol was a health and social issue not an agriculture issue like in the European Union (EU). However, the constituency of the EU requires a high level of human protection in the definition and implementation of all community policies and activities. This legal background was the rationale and backbone of the activities during the Finnish European Union presidency in 2006 when Finland launched the new concept ‘Health in All Policies’ that reflected the work done in Finland already decades. The reasons for
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The emphasis on addressing the social, economic and environmental determinants of health was reiterated in the Declaration of Alma Ata and the Ottawa Charter for Health Promotion, and has been central to the focus of all other global health promotion conferences from Ottawa to Helsinki, particularly the one held in Adelaide on Healthy Public Policies. The call to action for implementing the HiAP approach issued at the Helsinki Conference has been further strengthened by the Political Declaration on Social Determinants of Health (WHO, 2011a), the UN Political Declaration on Noncommunicable Diseases Prevention and Control (UN, 2012a) and the Rioþ 20 Outcome Document (the Future We Want) (UN, 2012b). Over the years, the understanding of HiAP has become increasingly clear, from the focus on health and health equity to the inclusion of additional emphases such as health protection and health system performance. The term has also been defined. HiAP is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity. It improves accountability of policymakers for health impacts at all levels of policy-making. It includes an emphasis on the consequences of public policies on health systems, determinants of health and well-being. There have been attempts to dissect and distinguish the meaning and notion of the term HiAP from other terms such as Whole of Government, intersectoral action (ISA) and multisectoral action (MSA). Calling spades spades, all of these terms and concepts are about engagement with determinants of health within and beyond the health sector. Therefore, to achieve better health and health equity, governments are required to work across ministries and programmes. It has become more urgent than ever to address policy issues beyond a more biomedical model of health because of the glocalization of the world: on the one hand global issues and patterns require larger scale solutions (such as, for instance, climate change or the international financial situation), while on the other the local impacts of these are most direly felt by individuals among the billion poor (Sumner, 2010). The host of social and economic glocalized factors such as commodification and urbanization can create conditions that make healthy choices harder choices.
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‘economic arguments’, ‘social change for health’, ‘responding to health inequities’, ‘capacity building’ and ‘the how-to of HiAP/MSA: best practice, successes and lessons learned’. Some 20 field visits were also organized by the Finnish Ministry of Social Affairs and Health to demonstrate how HiAP works. In this Supplement, the Conference outcome documents are presented: the Helsinki Statement on Health in All Policies (WHO, 2013b) and the HiAP Framework for Country Action (WHO, 2014). In addition, there are 11 technical papers that were presented at the Conference. Koivusalo and Labonte analyse the global health context for HiAPs. Scheil-Adlung then reviews the importance of social protection mechanisms for health equity, Rashad and Khadr describe how measuring health equity would impact policy development and Al-Bahlani and Mabry present a regional first overview of legislation for better health and health equity in Oman. This is complemented by an analysis by Rantala et al. on the establishment of HiAP at the local level. Sassi and Belloni analyse the economic drivers and imperatives for HiAPs, with Peuchaud and Kontunen et al. taking a look at social change, demographic shifts and social media as tools and resources for policy development. Finally, Baumann et al. and Baum et al. both present evaluation frameworks for HiAP, leading to increasing and more responsive policy-making capacity. Interestingly, Bauman et al. take a more orthodox health promotion view of complexity and human behaviour, whereas Baum et al. are driven by political science and a sociology of change. Although we might say that political problems require a political science lens, and policy problems policy studies, Bauman’s health education gaze may be appealing to many, and together these two perspectives may well offer a future HiAP research agenda. WHERE WE ARE NOW Let us take a quick scan of where we are now. The scan is not meant to produce an exhaustive search on this topic area but simply a reflection of what has been achieved through the conference process and other WHO initiatives over the last few years. The main achievements of the conference are putting HiAP application on truly international
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putting HiAP on the European Union agenda was that the Ministry of Social Affairs and Health felt that policies in the EU did not consider health appropriately; the EU policymaking system did not fully utilized all structures and measures available, e.g. the use of impact assessments; and there was seen an implementation gap on how health was integrated in community policies. After a high-level presidency conference in Kuopio, Finland, production of the book on HiAPs (Sta˚hl et al., 2006), and adoption of the Council Conclusions by EU Council of Health Ministers on Health in All Policies, the theme was further implemented in the European Commission’s work (Puska and Sta˚hl, 2010). To build on the gains in health promotion since 1986 and implement the Political Declarations on Social Determinants of Health and on Noncommunicable Diseases Prevention and Control, as well as the Rioþ20 Outcome Document, the time was mature in bringing the HiAP approach as the theme of the 8th Global Conference on Health Promotion. In developing the programme logic for the conference, its Scientific Committee considered the necessity to develop a number of building blocks that cut across and link with each other. First, in order to achieve HiAPs, the policy-making of nonhealth sectors must be understood. Those sectors must be made aware of both the benefits of and need for making health-friendly policies. The whole government needs to be mobilized and the health sector should be the prime mover. Towards these ends, this Conference sought to deliver the ‘how-to’ for facilitating policy-making by non-health sectors to realize both the particular sector’s objectives as well as the health sector objectives, achieving a win – win situation. Three key factors that facilitate health-oriented policymaking were determined: economic impact of poor health, social change for health and health inequities. The conference programme strongly hinged on these factors. The conference participants also looked at issues in capacity building for HiAP. To enable countries to take action, its capacity needs to be built to make full use of the ‘how-to’ that has been developed. In addition to a ‘Europe Day’ where members of the European Region of WHO showcased their efforts in HiAP and strategies for health equity, six themes ran across the conference programme: ‘policy-making of non-health sectors’,
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and progress. HiAP application can be further advanced by strengthening country institutional capacity, including policies, human and financial resources as well as collaborative mechanisms. Major tasks lie ahead to build such a capacity for evidence-based practices. The field is rapidly gaining momentum and substance. A range of models, checklists and inventories has been initiated by or developed in parallel with the conference (Freiler et al., 2013; Hendriks et al., 2014; Kickbusch and Gleicher, 2012; Leppo 2013; McQueen et al., 2012; Rudolph et al., 2013; WHO, 2011b) including a book produced by the host as unofficial material for the Conference, with a global authorship, that explored experience of improving health and equity through cross-sectoral polices and stressed the need to understand the nature of the problems, identify policy options and understand that policy-making involved politics. (Leppo et al., 2013). The HiAP Framework for Country Action, together with the Helsinki Statement on HiAP, provides guidance for countries as they take the next steps to put HiAPs. This will be a useful tool in the implementation package to sustain the momentum that has been built through the 8th Global Conference. For effective implementation, training is required and demonstrating projects needs to be set up. To facilitate, a WHO HiAP Training Manuel will be launched in the second half of 2014. To support country action and as a follow-up of the 8th Global Conference, a Resolution (WHA67.12) has been adopted at the World Health Assembly held in May 2014 (available at http://apps.who.int/gb/ebwha/pdf_files/WHA67/ A67_R12-en.pdf ). As set out in the Resolution, WHO Member States are urged to champion health and the promotion of health equity as a priority; to take steps including, where appropriate, effective legislation, cross-sectoral structure processes, methods and resources that enable societal policies which take into account and address their impact on health determinants; to take action to enhance health and safeguard public health interests from undue influence by any form of conflict of interest; to include relevant stakeholders such as local communities and civil society in the development, implementation and monitoring of policies across sectors; to identify synergy between health and other sector policy objectives; and, to contribute to the development of the post 2015 development agenda.
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and global agenda both on scientific and intergovernmental spheres; gaining consensus of the definition of the concept through Action: SDH, an electronic discussion platform created by WHO; publishing country case studies on HiAP; producing the Helsinki Statement on HiAP and the HiAP Framework for Country Action and creating and getting the political commitment and momentum within the global health promotion family for the implementation of the approach. While the value of the approach to achieving better health and health equity through action across sectors is certain, consensus on the use of term ‘health in all policies’ has not yet been achieved. Nevertheless, despite arguments about semantics which can be dealt with in another paper, real progress is being made to HiAP application. The WHO Regional Office for Africa (AFRO) has published a report entitled ‘HiAP: Report on perspectives and intersectoral actions’. The WHO Regional Office for the Americas (AMRO)/Pan American Health Organization (PAHO) is preparing a plan of action on HiAP in response to the recommendations made by the Region’s country focal points on health promotion and social determinants of health and in line with the regional strategic plan 2014–2019. The plan of action will be considered at the PAHO Executive Committee Meeting to be held in June 2014. The WHO Regional Office for the Eastern Mediterranean (EMRO) is in the process of drafting a guide for developing MSA plans in response to the request by the Member States for technical assistance in combating noncommunicable diseases (NCD). The approach has been considered by the Member States in the WHO European Region as a central thrust to the implementation of the Health 2020. A regional HiAP Framework for Country Action has also been finalized by the Member States in the WHO South-East Asia Region (SEAR). Progress on HiAP application will also be featured at the upcoming 9th Global Conference on Health Promotion to be hosted in the WHO Western Pacific Region (WPR). The WHO Centre for Health Development, Kobe is also reviewing a how to guide on ISA. Examples of HiAP and action across sectors have also been found in 50 countries. Based on .20 case studies in the WHO African Region, SEAR and WPR, an analytic framework was also developed (WHO, 2013c). A snapshot of the work at the country level reveals strong commitment but uneven capacity
Editorial
UNFINISHED BUSINESS: THE WAY FORWARD Putting HiAPs is not an exact science. Its scholarly foundations embrace not only medical and health sciences but also social and political sciences, taking a host of factors into account, be they power dynamics, needs and wants, funding and expertise as well as political expedience. The application of HiAP requires conscientious effort and judicious use of evidence. To maximize impact of application, theory-driven practices are essential. Theory-driven practices can be constructed from a number of perspectives. Clearly, when policy is the object of research and development, the political sciences come to mind (Clavier and de Leeuw, 2013), but another perspective that may be applied is that of Lewin and Rogers (Butterfoss et al., 2008) on the stage theory of organizational change, which implies that the approach will likely be taken up by a ministry in which decision-makers are increasingly more aware of the importance and usefulness of the HiAP approach, followed by decisions to adopt or adapt the approach and by activities to implement the approach, and to sustain action and institutionalize the approach. In this regard, a series of activities is to be undertaken in each of the stages of organizational change. To promote awareness of a problem and possible solutions, some pointers for consideration are: Was the approach used elsewhere, particularly in countries with a similar level of
development and how was the experience? Are the ‘what works’ and ‘how it work’ known? For policy-makers to adopt/adapt the approach, cues include: Will it be a winner for the decision-maker to use it and what are the draw backs if not? What are the legal and financial implications for adopting the approach? What are the risks for not using the approach? Will health policy be determined by other sector policies without considering the potential health impacts or harms? Will technical support be available regionally and internationally? Implementation may necessitate redefining the innovation and modifying organizational structures. Some key considerations for implementation are: How can I use evidence for defining the battle ground and forming a basis for negotiation? Who are my allies and how can their roles be delineated? Do I need a set of planned action with clear priorities and objectives and measurement of success? How can agreements between sectors be reached and to what extent can resources be shared or pooled? How well was the application implemented and what could have been done better? To institutionalize and make innovation part of the organization’s ongoing activities will be required to sustain HiAP application. In this regard, ongoing designated staff and budget line as well as opportunities for staff to work across sectors on policies that impact on health are essential. Policy is essential and the application needs to operate on at least a routine if not an optimal basis; an ad hoc basis is not institutionalization (Goodman et al., 1993). The response by stakeholders involved to the application in terms of satisfaction and changes in attitudes and beliefs needs to be examined. Fine tuning the current organizational structure or policies to accommodate the approach and change may also be required. Research and monitoring remain central to effective HiAP application. Research findings are required for sectors to progress the development. To name a few, what sort of political commitment do we need and how best can the commitments be fulfilled? Who are the prime movers at different stages of activities? What are the contributing and resisting factors under different socio-cultural context and political economy? How can the impact of HiAP application be assessed and reported? With a boom of HiAP literature over the past few years, theoretical models and how-to guides
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The WHO Secretariat is also required in consultation with Member States, to develop a Framework for Country Action, for adaptation to different contexts, taking into account the Helsinki Statement on HiAP, aimed at supporting national efforts to improve health and health equity through action across sectors on determinants of health and NCD risk factors; to provide technical assistance, upon request, to Member States in their efforts towards implementation of HiAP and to continue to work with UN bodies to take health considerations into account in major strategic initiatives and their monitoring (in the post-2015 development agenda) and urge these organizations to achieve coherence and synergy with commitments and obligations related to health and health determinants in their work with Member States.
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DISCLAIMER K. C. Tang is a staff member of the World Health Organization. The author alone is responsible for the views in this publication and they do not necessarily represent the decision, policies or views of the World Health Organization. T. Sta˚hl is a staff member of the National Institute for Health and Welfare (THL), Finland; he was seconded to WHO for two years from August 2011. The author is responsible for the views in this publication and they do not necessarily represent the decision, policies or views of the World Health Organization or THL.
D. W. Bettcher is a staff member of the World Health Organization. The author alone is responsible for the views in this publication and they do not necessarily represent the decision, policies or views of the World Health Organization.
CONFLICT OF INTEREST E. de Leeuw is Editor-in-Chief of Health Promotion International; she acted as Rapporteur at the Eighth Global Conference on Health Promotion; and was contracted by WHO to perform follow-up work on Health in All Policies documents since June, 2013. The author alone is responsible for the views in this publication and they do not necessarily represent the decision, policies or views of the World Health Organization, Health Promotion International, or Oxford University Press. Kwok Cho Tang1, Timo Sta˚hl2, Douglas Bettcher3 and Evelyne De Leeuw4 1 Health Promotion, World Health Organization, Geneva, Switzerland,2National Institute for Health and Welfare, Helsinki, Finland, 3 Department of Prevention of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland and 4Health Promotion International, Melbourne, Australia and Oxford, United Kingdom [email protected]
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have become more readily available together with a relatively large number of case studies. While the face validity of these models and guides looks promising, the construct validity is still unresolved, and not supported by strong evidence through triangulation, of both qualitative and quantitative methods; of different theoretical insights; through scholars from a range of disciplines; across time and cultures and with a strong practice base. To continue to advance HiAP application, those case studies need to be synthesized systematically to build a body of knowledge and evidence that is pertinent to the complexities of cross-sector policy-making. Efforts are also required for developing objective quantifiable measures and pathways with statistical analysis and beyond the pure numerical quantification of insights, for using ‘realist synthesis’ (Pawson et al., 2004; Whitfield et al., 2013) in which a rigorous programme logic drives collection of a range of data through multi-method approaches to compile compelling sets of evidence. But action speaks louder than words. This Supplement, beyond including a range of cuttingedge conceptual propositions on HiAPs, also delivers practical applications in areas of social change, global health, migrant well-being, economics, social protection and legislation parameters, etc. The Helsinki conference recharged the global health promotion community towards integrated policy responses for health. We now need to effectively implement the Resolution and continue action for HiAP. To quote two great minds of the 20th century, to illustrate the importance of action, Gandhi said ‘action expresses priorities’ and Einstein ‘Human beings must have action; and they will make it if they cannot find it’.
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a HiAP case study. Health Promotion International, 29(Suppl. 1), i113–i120. Porter, R. (1997) The Greatest Benefit to Mankind: A Medical History of Humanity. HarperCollins, London. Puska, P. and Sta˚hl, T. (2010) Health in all policies—the Finnish initiative: background, principles, and current issues. Annual Review Public Health, 31, 315–328. Rantala, R., Bortz, M. and Armada, F. (2014) Intersectoral action: local governments promoting health. Health Promotion International, 29(Suppl. 1), i59 –i69. Ra¨sa¨nen, L. (2007) Of all foods bread is the most noble: Carl von Linne´ (Carl Linnaeus) on bread. Food and Nutrition Research, 51, 91– 99. Rashad, H. and Khadr, Z. (2014) Measurement of health equity as a driver for impacting policies. Health Promotion International, 29(Suppl. 1), i79 –i93. Rosen, G. (1993) A History of Public Health. JHU Press, Baltimore. Rudolph, L., Caplan, J., Ben-Moshe, K. and Dillon, L. (2013) Health in All Policies: A Guide for State and Local Governments. American Public Health Association and Public Health Institute, Washington, DC and Oakland, CA. Sassi, F. and Belloni, A. (2014) Fiscal incentives, behaviour change and health promotion: what place in the health-inall-policies toolkit? Health Promotion International, 29(Suppl. 1), i103–i112. Scheil-Adlung, X. (2014) Response to health inequity: the role of social protection in reducing poverty and achieving equity. Health Promotion International, 29(Suppl. 1), i70 –i78. Snow, J. (1855) On the Mode of Communication of Cholera. John Churchill, London. Sta˚hl, T., Wismar, M., Ollila, E., Lahtinen, E. and Leppo, K. (2006) Health in All Policies. Prospects and Potentials. Ministry of Social Affairs and Health, Finland, Helsinki. Strazullo, P., D’Elia, L., Kandala, N. B. and Cappuccio, F. P. (2009) Salt intake, stroke and cardiovascular disease: meta-analysis of prospective studies. BMJ, 339, 1– 9. Sumner, A. (2010) Global poverty and the new bottom billion: three-quarters of the world’s poor live in middle-income countries. International Policy Centre for Inclusive Growth One Pager, 120, 1 –43. United Nations. (2009) Secretary-General’s Ban Ki-Moon Statement to the World Health Assembly. UN, Geneva. United Nations. (2010) Global plan for the decade of action for road safety 2011–2020. United Nations. (2012a) Political declaration of the highlevel meeting of the general assembly on the prevention and control of non-communicable diseases. A/RES/66/2. United Nations. (2012b) The future we want. A/CONF.216/L.1. Whitfield, M., Machaczek, K. and Green, G. (2013) Developing a model to estimate the potential impact of municipal investment on city health. Journal of Urban Health, 90, 62– 73. Winslow, C. E. (1920) The untilled fields of public health. Science, 51, 23–33. World Health Organization. (2007) Evolution of Public Health Security. In World Health Organization, A safer future: global public health security in the 21st century, Chapter 1. WHO, Geneva, pp. 1 –11. World Health Organization. (2011a) Rio political declaration on social determinants of health. World Conference on Social Determinants of Health. , Brazil. World Health Organization. (2011b) Global status report on noncommunicable diseases 2010. WHO.
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# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
EDITORIAL
The Eighth Global Conference on Health Promotion: Health in All Policies: From Rhetoric to Action
THE HIAP ARGUMENT ‘We must remember health is an outcome of all policies’, United Nations (UN) Secretary General Ban Ki Moon said in his Statement to the 2009 World Health Assembly (UN, 2009). Similar claims have become increasingly commonplace, including the remark by the Director-General of the World Health Organization (WHO) Margaret Chan at the opening of the 8th Global Conference on Health Promotion: ‘The HiAP makes perfect sense. The determinants of health are exceptionally broad. Policies made in other sectors can have a profound, and often adverse, effect on health’ (WHO, 2013a). These claims are well established and based on evidence. The profound impact of all public
policies on health has been comprehensively mapped (Milio, 1981). To list a few examples of how health is impacted by policies beyond the health sector, death rates due to road traffic incidents have declined by over 60% in Australia, France, Sweden and UK over the past four decades (UN, 2010; Krug, 2013), as a result of a set of evidence-based practices including road engineering and motor vehicle safety measures. A reduction of 5 g of salt intake from 10 g per day reduces the rates of stroke by 23% and the overall rates of cardiovascular disease by 17% (Strazullo et al., 2009). Raising taxes on tobacco and alcohol has already saved and will continue to save thousands of lives. Detrimental policies beyond the health sector include poor occupational safety and health practices which lead to not only deaths and injuries but also economic losses up to 4– 5% of global gross domestic product each year (ILO, 2014). Action across sectors has also been proven essential to combating communicable diseases such as cholera centuries ago and like SARS more recently (Lai and Tan, 2012; Ching et al., 2013). These claims also build on the foresight of many public health pioneers including Linnaeus in Sweden in the 17th Century (Asp, 2007; Ra¨sa¨nen, 2007), Snow and Chadwick(Chadwick, 1842; Snow, 1855) in the mid-19th Century in the UK and by Winslow (Winslow, 1920) in the early 20th century in the USA. They all agreed on the need to address issues beyond personal hygiene and quality health care and to look at particularly living and working conditions (Rosen, 1993; Porter, 1997). HiAP application was also established as early as the 7th century in China when quarantine was a public health practice, detaining sailors and foreign travellers suffering from plague (WHO, 2007) (http://www.who.int/whr/ 2007/07_chap1_en.pdf ). i1
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Between 9 and 14 June 2013, some 650 expert participants from 122 countries met in the Finlandia Hall in Helsinki, Finland with one common goal: to advance the practical approaches for implementing the health-in-all-policies (HiAP) approach. This Supplement of the Journal presents core documents that were prepared before, during and after the Conference. Manuscripts were peer reviewed with the assistance and diligence of a Guest Editorial Board. The editors would like to take this opportunity to thank the members of the Conference Organizing and Scientific Committees for their contributions to achieving better health and health equity through application of HiAP and other actions across sectors, in particular, the production of the Helsinki Statement on Health in All Polices and the HiAP Framework for Country Action. A full list of the members is available at http://www. who.int/healthpromotion/conferences/8gchp/en/.
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Immediate action is warranted. The mandate is clear and the needs and opportunities are obvious. Rhetoric is easy, and we need to move towards tangible, concrete and replicable insights into how integrated policy responses to complex health issues come about. What is missing is the body of knowledge that maps determinants of policy effectiveness and the processes involved, what the building blocks are for putting health in all policies (HiAP) and how policy coherence for health promotion can be achieved, given that governments always have a range of priorities and health and its equity are not automatically at the top of the list. THE FOUNDATIONS OF THE EIGHTH GLOBAL CONFERENCE ON HEALTH PROMOTION The Finnish Government illustrated the importance of a HiAPs approach, given their long history for horizontal, comprehensive health policy. The roots of the Finnish Health in All Policies approach can be traced back to 1972 when the Economic Council of Finland (The Economic Council of Finland, chaired by the Prime Minister, is a body for facilitating cooperation between the government and major interest groups. It discusses economic and social issues that are of central importance to the success of the nation.) recognized the need for comprehensive health policy and set sector-specific health objectives outside health sector, e.g. to prevent road accidents and deaths (Economic Council, 1972). Since then, other government ministries have also discussed and developed policies which consider health. At the time when Finland joined the European Union in 1995 some power was given to European Union so that Finland did not have any more complete control over its health policy, e.g. restricting travellers’ alcohol and cigarette quotas from abroad—in Finland the alcohol was a health and social issue not an agriculture issue like in the European Union (EU). However, the constituency of the EU requires a high level of human protection in the definition and implementation of all community policies and activities. This legal background was the rationale and backbone of the activities during the Finnish European Union presidency in 2006 when Finland launched the new concept ‘Health in All Policies’ that reflected the work done in Finland already decades. The reasons for
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The emphasis on addressing the social, economic and environmental determinants of health was reiterated in the Declaration of Alma Ata and the Ottawa Charter for Health Promotion, and has been central to the focus of all other global health promotion conferences from Ottawa to Helsinki, particularly the one held in Adelaide on Healthy Public Policies. The call to action for implementing the HiAP approach issued at the Helsinki Conference has been further strengthened by the Political Declaration on Social Determinants of Health (WHO, 2011a), the UN Political Declaration on Noncommunicable Diseases Prevention and Control (UN, 2012a) and the Rioþ 20 Outcome Document (the Future We Want) (UN, 2012b). Over the years, the understanding of HiAP has become increasingly clear, from the focus on health and health equity to the inclusion of additional emphases such as health protection and health system performance. The term has also been defined. HiAP is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity. It improves accountability of policymakers for health impacts at all levels of policy-making. It includes an emphasis on the consequences of public policies on health systems, determinants of health and well-being. There have been attempts to dissect and distinguish the meaning and notion of the term HiAP from other terms such as Whole of Government, intersectoral action (ISA) and multisectoral action (MSA). Calling spades spades, all of these terms and concepts are about engagement with determinants of health within and beyond the health sector. Therefore, to achieve better health and health equity, governments are required to work across ministries and programmes. It has become more urgent than ever to address policy issues beyond a more biomedical model of health because of the glocalization of the world: on the one hand global issues and patterns require larger scale solutions (such as, for instance, climate change or the international financial situation), while on the other the local impacts of these are most direly felt by individuals among the billion poor (Sumner, 2010). The host of social and economic glocalized factors such as commodification and urbanization can create conditions that make healthy choices harder choices.
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‘economic arguments’, ‘social change for health’, ‘responding to health inequities’, ‘capacity building’ and ‘the how-to of HiAP/MSA: best practice, successes and lessons learned’. Some 20 field visits were also organized by the Finnish Ministry of Social Affairs and Health to demonstrate how HiAP works. In this Supplement, the Conference outcome documents are presented: the Helsinki Statement on Health in All Policies (WHO, 2013b) and the HiAP Framework for Country Action (WHO, 2014). In addition, there are 11 technical papers that were presented at the Conference. Koivusalo and Labonte analyse the global health context for HiAPs. Scheil-Adlung then reviews the importance of social protection mechanisms for health equity, Rashad and Khadr describe how measuring health equity would impact policy development and Al-Bahlani and Mabry present a regional first overview of legislation for better health and health equity in Oman. This is complemented by an analysis by Rantala et al. on the establishment of HiAP at the local level. Sassi and Belloni analyse the economic drivers and imperatives for HiAPs, with Peuchaud and Kontunen et al. taking a look at social change, demographic shifts and social media as tools and resources for policy development. Finally, Baumann et al. and Baum et al. both present evaluation frameworks for HiAP, leading to increasing and more responsive policy-making capacity. Interestingly, Bauman et al. take a more orthodox health promotion view of complexity and human behaviour, whereas Baum et al. are driven by political science and a sociology of change. Although we might say that political problems require a political science lens, and policy problems policy studies, Bauman’s health education gaze may be appealing to many, and together these two perspectives may well offer a future HiAP research agenda. WHERE WE ARE NOW Let us take a quick scan of where we are now. The scan is not meant to produce an exhaustive search on this topic area but simply a reflection of what has been achieved through the conference process and other WHO initiatives over the last few years. The main achievements of the conference are putting HiAP application on truly international
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putting HiAP on the European Union agenda was that the Ministry of Social Affairs and Health felt that policies in the EU did not consider health appropriately; the EU policymaking system did not fully utilized all structures and measures available, e.g. the use of impact assessments; and there was seen an implementation gap on how health was integrated in community policies. After a high-level presidency conference in Kuopio, Finland, production of the book on HiAPs (Sta˚hl et al., 2006), and adoption of the Council Conclusions by EU Council of Health Ministers on Health in All Policies, the theme was further implemented in the European Commission’s work (Puska and Sta˚hl, 2010). To build on the gains in health promotion since 1986 and implement the Political Declarations on Social Determinants of Health and on Noncommunicable Diseases Prevention and Control, as well as the Rioþ20 Outcome Document, the time was mature in bringing the HiAP approach as the theme of the 8th Global Conference on Health Promotion. In developing the programme logic for the conference, its Scientific Committee considered the necessity to develop a number of building blocks that cut across and link with each other. First, in order to achieve HiAPs, the policy-making of nonhealth sectors must be understood. Those sectors must be made aware of both the benefits of and need for making health-friendly policies. The whole government needs to be mobilized and the health sector should be the prime mover. Towards these ends, this Conference sought to deliver the ‘how-to’ for facilitating policy-making by non-health sectors to realize both the particular sector’s objectives as well as the health sector objectives, achieving a win – win situation. Three key factors that facilitate health-oriented policymaking were determined: economic impact of poor health, social change for health and health inequities. The conference programme strongly hinged on these factors. The conference participants also looked at issues in capacity building for HiAP. To enable countries to take action, its capacity needs to be built to make full use of the ‘how-to’ that has been developed. In addition to a ‘Europe Day’ where members of the European Region of WHO showcased their efforts in HiAP and strategies for health equity, six themes ran across the conference programme: ‘policy-making of non-health sectors’,
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and progress. HiAP application can be further advanced by strengthening country institutional capacity, including policies, human and financial resources as well as collaborative mechanisms. Major tasks lie ahead to build such a capacity for evidence-based practices. The field is rapidly gaining momentum and substance. A range of models, checklists and inventories has been initiated by or developed in parallel with the conference (Freiler et al., 2013; Hendriks et al., 2014; Kickbusch and Gleicher, 2012; Leppo 2013; McQueen et al., 2012; Rudolph et al., 2013; WHO, 2011b) including a book produced by the host as unofficial material for the Conference, with a global authorship, that explored experience of improving health and equity through cross-sectoral polices and stressed the need to understand the nature of the problems, identify policy options and understand that policy-making involved politics. (Leppo et al., 2013). The HiAP Framework for Country Action, together with the Helsinki Statement on HiAP, provides guidance for countries as they take the next steps to put HiAPs. This will be a useful tool in the implementation package to sustain the momentum that has been built through the 8th Global Conference. For effective implementation, training is required and demonstrating projects needs to be set up. To facilitate, a WHO HiAP Training Manuel will be launched in the second half of 2014. To support country action and as a follow-up of the 8th Global Conference, a Resolution (WHA67.12) has been adopted at the World Health Assembly held in May 2014 (available at http://apps.who.int/gb/ebwha/pdf_files/WHA67/ A67_R12-en.pdf ). As set out in the Resolution, WHO Member States are urged to champion health and the promotion of health equity as a priority; to take steps including, where appropriate, effective legislation, cross-sectoral structure processes, methods and resources that enable societal policies which take into account and address their impact on health determinants; to take action to enhance health and safeguard public health interests from undue influence by any form of conflict of interest; to include relevant stakeholders such as local communities and civil society in the development, implementation and monitoring of policies across sectors; to identify synergy between health and other sector policy objectives; and, to contribute to the development of the post 2015 development agenda.
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and global agenda both on scientific and intergovernmental spheres; gaining consensus of the definition of the concept through Action: SDH, an electronic discussion platform created by WHO; publishing country case studies on HiAP; producing the Helsinki Statement on HiAP and the HiAP Framework for Country Action and creating and getting the political commitment and momentum within the global health promotion family for the implementation of the approach. While the value of the approach to achieving better health and health equity through action across sectors is certain, consensus on the use of term ‘health in all policies’ has not yet been achieved. Nevertheless, despite arguments about semantics which can be dealt with in another paper, real progress is being made to HiAP application. The WHO Regional Office for Africa (AFRO) has published a report entitled ‘HiAP: Report on perspectives and intersectoral actions’. The WHO Regional Office for the Americas (AMRO)/Pan American Health Organization (PAHO) is preparing a plan of action on HiAP in response to the recommendations made by the Region’s country focal points on health promotion and social determinants of health and in line with the regional strategic plan 2014–2019. The plan of action will be considered at the PAHO Executive Committee Meeting to be held in June 2014. The WHO Regional Office for the Eastern Mediterranean (EMRO) is in the process of drafting a guide for developing MSA plans in response to the request by the Member States for technical assistance in combating noncommunicable diseases (NCD). The approach has been considered by the Member States in the WHO European Region as a central thrust to the implementation of the Health 2020. A regional HiAP Framework for Country Action has also been finalized by the Member States in the WHO South-East Asia Region (SEAR). Progress on HiAP application will also be featured at the upcoming 9th Global Conference on Health Promotion to be hosted in the WHO Western Pacific Region (WPR). The WHO Centre for Health Development, Kobe is also reviewing a how to guide on ISA. Examples of HiAP and action across sectors have also been found in 50 countries. Based on .20 case studies in the WHO African Region, SEAR and WPR, an analytic framework was also developed (WHO, 2013c). A snapshot of the work at the country level reveals strong commitment but uneven capacity
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UNFINISHED BUSINESS: THE WAY FORWARD Putting HiAPs is not an exact science. Its scholarly foundations embrace not only medical and health sciences but also social and political sciences, taking a host of factors into account, be they power dynamics, needs and wants, funding and expertise as well as political expedience. The application of HiAP requires conscientious effort and judicious use of evidence. To maximize impact of application, theory-driven practices are essential. Theory-driven practices can be constructed from a number of perspectives. Clearly, when policy is the object of research and development, the political sciences come to mind (Clavier and de Leeuw, 2013), but another perspective that may be applied is that of Lewin and Rogers (Butterfoss et al., 2008) on the stage theory of organizational change, which implies that the approach will likely be taken up by a ministry in which decision-makers are increasingly more aware of the importance and usefulness of the HiAP approach, followed by decisions to adopt or adapt the approach and by activities to implement the approach, and to sustain action and institutionalize the approach. In this regard, a series of activities is to be undertaken in each of the stages of organizational change. To promote awareness of a problem and possible solutions, some pointers for consideration are: Was the approach used elsewhere, particularly in countries with a similar level of
development and how was the experience? Are the ‘what works’ and ‘how it work’ known? For policy-makers to adopt/adapt the approach, cues include: Will it be a winner for the decision-maker to use it and what are the draw backs if not? What are the legal and financial implications for adopting the approach? What are the risks for not using the approach? Will health policy be determined by other sector policies without considering the potential health impacts or harms? Will technical support be available regionally and internationally? Implementation may necessitate redefining the innovation and modifying organizational structures. Some key considerations for implementation are: How can I use evidence for defining the battle ground and forming a basis for negotiation? Who are my allies and how can their roles be delineated? Do I need a set of planned action with clear priorities and objectives and measurement of success? How can agreements between sectors be reached and to what extent can resources be shared or pooled? How well was the application implemented and what could have been done better? To institutionalize and make innovation part of the organization’s ongoing activities will be required to sustain HiAP application. In this regard, ongoing designated staff and budget line as well as opportunities for staff to work across sectors on policies that impact on health are essential. Policy is essential and the application needs to operate on at least a routine if not an optimal basis; an ad hoc basis is not institutionalization (Goodman et al., 1993). The response by stakeholders involved to the application in terms of satisfaction and changes in attitudes and beliefs needs to be examined. Fine tuning the current organizational structure or policies to accommodate the approach and change may also be required. Research and monitoring remain central to effective HiAP application. Research findings are required for sectors to progress the development. To name a few, what sort of political commitment do we need and how best can the commitments be fulfilled? Who are the prime movers at different stages of activities? What are the contributing and resisting factors under different socio-cultural context and political economy? How can the impact of HiAP application be assessed and reported? With a boom of HiAP literature over the past few years, theoretical models and how-to guides
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The WHO Secretariat is also required in consultation with Member States, to develop a Framework for Country Action, for adaptation to different contexts, taking into account the Helsinki Statement on HiAP, aimed at supporting national efforts to improve health and health equity through action across sectors on determinants of health and NCD risk factors; to provide technical assistance, upon request, to Member States in their efforts towards implementation of HiAP and to continue to work with UN bodies to take health considerations into account in major strategic initiatives and their monitoring (in the post-2015 development agenda) and urge these organizations to achieve coherence and synergy with commitments and obligations related to health and health determinants in their work with Member States.
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DISCLAIMER K. C. Tang is a staff member of the World Health Organization. The author alone is responsible for the views in this publication and they do not necessarily represent the decision, policies or views of the World Health Organization. T. Sta˚hl is a staff member of the National Institute for Health and Welfare (THL), Finland; he was seconded to WHO for two years from August 2011. The author is responsible for the views in this publication and they do not necessarily represent the decision, policies or views of the World Health Organization or THL.
D. W. Bettcher is a staff member of the World Health Organization. The author alone is responsible for the views in this publication and they do not necessarily represent the decision, policies or views of the World Health Organization.
CONFLICT OF INTEREST E. de Leeuw is Editor-in-Chief of Health Promotion International; she acted as Rapporteur at the Eighth Global Conference on Health Promotion; and was contracted by WHO to perform follow-up work on Health in All Policies documents since June, 2013. The author alone is responsible for the views in this publication and they do not necessarily represent the decision, policies or views of the World Health Organization, Health Promotion International, or Oxford University Press. Kwok Cho Tang1, Timo Sta˚hl2, Douglas Bettcher3 and Evelyne De Leeuw4 1 Health Promotion, World Health Organization, Geneva, Switzerland,2National Institute for Health and Welfare, Helsinki, Finland, 3 Department of Prevention of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland and 4Health Promotion International, Melbourne, Australia and Oxford, United Kingdom [email protected]
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have become more readily available together with a relatively large number of case studies. While the face validity of these models and guides looks promising, the construct validity is still unresolved, and not supported by strong evidence through triangulation, of both qualitative and quantitative methods; of different theoretical insights; through scholars from a range of disciplines; across time and cultures and with a strong practice base. To continue to advance HiAP application, those case studies need to be synthesized systematically to build a body of knowledge and evidence that is pertinent to the complexities of cross-sector policy-making. Efforts are also required for developing objective quantifiable measures and pathways with statistical analysis and beyond the pure numerical quantification of insights, for using ‘realist synthesis’ (Pawson et al., 2004; Whitfield et al., 2013) in which a rigorous programme logic drives collection of a range of data through multi-method approaches to compile compelling sets of evidence. But action speaks louder than words. This Supplement, beyond including a range of cuttingedge conceptual propositions on HiAPs, also delivers practical applications in areas of social change, global health, migrant well-being, economics, social protection and legislation parameters, etc. The Helsinki conference recharged the global health promotion community towards integrated policy responses for health. We now need to effectively implement the Resolution and continue action for HiAP. To quote two great minds of the 20th century, to illustrate the importance of action, Gandhi said ‘action expresses priorities’ and Einstein ‘Human beings must have action; and they will make it if they cannot find it’.
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