16 Health in All Policies – All Talk and Little Action

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anada has long been a leader in establishing direction on population and public health through the relea of inspir-ing documents such as the Ottawa Charter for Health Pro-motion and the Epp Report, both published in 1986,1,2and legislation such as the Canada Health Act in 1984.3Numerous reports have been relead over the past three decades establishing the importance of improving the determinants of health and reduc-ing inequities, generating upstream interventions, or designing policies with health uppermost in mind.4-7The have parallels in other countries, notably England, in initiatives such as the White-hall studies (beginning in 1967) and the Marmot Review.8Recent-ly, the World Health Organization held a Commission on the Social Determinants of Health, led by Sir Michael Marmot and engaging Canadian leaders such as Monique Bégin in key roles.9

Health in All Policies (HiAP) is a type of large-scale interctoral action to improve health through attention to the full range of determinants. Becau it does not take a single form and tends to develop amlessly out of other initiatives, it is difficult to pinpoint exactly when or how it started. According to some rearchers, it was first instantiated in Sri Lanka in 1980, but the term has become much more common in the last decade.10Finland, which has been recognized as one of the pioneers in implementing HiAP , promot-ed HiAP as a theme of its 2006 presidency of the European Union,releasi

ng a comprehensive report on prospects for improving the social determinants of health through cross-government policy;11the principles have been reiterated at international conferences in Rome (in 2007)12and Adelaide (in 2010).13

Full operationalization of HiAP often requires new structures and process, whether a cabinet committee (England),14joined-up eval-uation process (Norway),14 a network of committees (Iran,Malaysia), or other arrangements.15,16There have been veral tools designed to help policy-makers analyze and document the poten-tial effects of HiAP . Developing new structures, process and tools challenges both political and public rvice leaders to ri above their own interests, consider shared goals and commit to steps for reaching them. However, despite the precedents, little disagree-ment with their rationale, and Canada’s early leadership on the issues, the operationalization of the strategies has been limited in Canada. Quebec is the only province to have formalized a sys-tem of asssing policies for health impacts,14and other provinces,such as British Columbia, have at best adopted short-term initia-tives to address health across government. We identify veral rea-sons for this state of affairs.

First, most governments are still divided into departments or ministries responsible for a specific area. The “silos” not only have their own goals and ministers, but also their own cultures and budg

ets, and do not, as a rule, work together. Health is often the largest ministry or department in provincial governments, taking up an average of 46% of provincial budgets in Canada.17Further,the monies are primarily spent on health care , with few desig-nated ministries or budgets for health promotion or prevention.HiAP and other forms of interctoral action require a paradigm shift from silos to joined-up government. The task of balancing departmental or ministerial budgets must be transformed by eing the government-wide budget as one pur. This attitude is not encouraged by the current protocol of making estimates and report-ing expenditures by ministry or department. Currently, cost sav-ings resulting from coordinated and integrated approaches to policy development across ctors are not calculated. Hence, non-© Canadian Public Health Association, 2011. All rights rerved.

CANADIAN JOURNAL OF PUBLIC HEALTH • NOVEMBER/DECEMBER 2011407

Health in All Policies – All Talk and Little Action?

Lorraine J. Greaves, PhD, DU,1 Lauren R. Bialystok, PhD 2

ABSTRACT

For three decades, Canadian and international rearchers have been suggesting that improving population and public health requires attention to a range of determinants and factors and that concerted and coordinated action on the part of non-health ministries and organizations might be necessary to achieve this goal. Suggestions have been made for collaboration and integration by explicitly designing interctoral actions and interventions and asssing the impact of all policies and programs for their effects on health. While some progress has been made on the goals, it is minor compared to the size of the problem. This article address one type of interctoral action, Health in All Policies (HiAP), and asks questions about why it has not gained a place in governments across Canada. Possible barriers are suggested, such as current structural and political factors that prevent long-range,shared strategies to improve health. Suggestions are made for generating economic and evaluative data on HiAP , developing more nsitive tools for measuring HiAP and adopting explicit “trans-ctoral” approaches to policy-making.Key words: Health in All Policies; social determinants; equity; interctoral action

La traduction du résumé trouve à la fin de l’article.

Can J Public Health

2011;102(6):407-9.

COMMENTARY

health ministers responsible for budgets and deliverables do not consider saving health expenditures, or even improving health, to be their work, their savings or their achievement.

寒衣节是哪一天Second, becau of this situation, it is especially important that there be evidence to illustrate that HiAP approaches work and are measurable and that non-health ministries have achieved results using HiAP in other jurisdictions. However, such evidence is limit-ed. While there is evidence that HiAP is a sound direction for addressing population health, it is generally correlative and descrip-tive, resting on assumptions about the links between inequities and economic demands on the health care system.7,18Economic data or modelling that would convince cash-strapped politicians and civil rvants to launch large change initiatives like HiAP are often missing.

Third, electoral cycles are not conducive to long-term strategies such as HiAP. Most governments ha

ve approximately four years between elections. This concentrated period is spent on reviewing and meeting platform commitments, in time for successful cam-paigning on met promis and achievements. Presumably the ben-efits of HiAP and related initiatives typically appear over the long term when the ministers and government responsible for imple-menting them will be long gone, and methods of counting the out-comes of such initiatives lost. Sustained commitment over veral mandates may be required to e results. For example, England’s reports on the Programme for Action reveal that policies in place since 1997 have begun to make a dent in child poverty, but that ongoing efforts are needed to address persisting inequalities.8In most governments, HiAP remains on the “back burner”, never becoming a critically important issue on which to build support. Fourth, ideological commitments do not always support the long-term, structural changes that bolstering health and well-being across a population may require. Many governments in recent years have argued that the best way to improve health is to improve income and rai employment levels, and the shortest route to the goals is economic stimulation, lower taxes, and creation of pro-business environments. Social determinants approaches often require more investment in social programs, wealth redistribution, and expensive public projects. For example, Brazil makes direct income transfers to approximately 45 million people living in poverty who, in return, agree to follow certain health protocols.19 Such approaches have not been consistently popular over the last thirty years, particularly in times of recession.

Finally, while many politicians and bureaucrats agree with, or do not disagree with, the goals of interctoral action to improve health, specifically HiAP, the changes required to effect it em overwhelming. Politicians and policy-makers typically need a spe-cial impetus to undertake this type of large-scale change, along with leadership, a vision and excellent messaging. For example, the 2010 Vancouver Olympics provided a window for the government of British Columbia to generate enough support to launch ActNow, an interctoral effort geared at making British Columbia the healthiest jurisdiction ever to host an Olympics.20Quebec is anoth-er Canadian jurisdiction that found an opportunity to broaden its approach to health during the rewriting of its Public Health Act in 2002. Section 54 was added to mandate Health Impact Asssment as part of the policy process in all Government departments.21 Without timely entry points such as the, HiAP-like efforts may not take root.

There is much agreement that HiAP is “the right thing to do”,“makes n” and is intuitively understood to save resources. How-ever, there is little empirical evidence of the outcomes of HiAP, and especially its economic impact. This prents a huge barrier to gov-ernments, especially in a recession, when experimentation is not likely to occur.

What are the solutions to this blockage? Three directions are crit-ical. First, more evaluation and eco

nomic modelling must be done by rearchers and health advocates who e HiAP as a solution. If clear economic models were developed according to policy-makers’ guidelines for measurement and evaluation, more data would emerge to convince leaders to endor HiAP. Some work is emerging in this area but it needs to be more specific.18In addition, evaluation schemes need to be developed that have some common outcome indicators across jurisdictions, so that HiAP can be exam-ined over time at a cross-jurisdictional level. Leadership and vision are required by a provincial or federal leader to push the ideas forward.

Second, effective tools need to be developed, tested and encour-aged for asssing non-health policies for their effects on health. While Health Impact Asssment (HIA) is mandated in Quebec, there is a need for increasingly critical and analytic tool develop-ment that can help to embed HiAP in non-health ministries.21 Health Equity Impact Asssment (HEIA) tools have been devel-oped in some jurisdictions, including Ontario; even more compre-hensive tools to support HiAP are required to integrate gender and diversity factors into analysis and encourage an interctionality lens that identifies complex relations between determinants of health.22The components would make sure that HiAP rhetoric is backed up by mandatory analys, allow for accountability meas-ures, and provide data regarding the predictions and process of policy-makers as they consider HiAP.

Finally, a shared paradigm needs to be developed and rendered mainstream in policy circles. An analogy can be drawn with trends in academic rearch over the past thirty years. At first, single dis-ciplines were encouraged to engage in inter- and multidisciplinary work, to increa the number of perspectives on an issue. Later, entirely different pillars of rearch were encouraged to create trans-disciplinary approaches, generating new methods, shared language and new theoretical approaches, again to better solve complex problems. Problems became redefined in holistic terms, rather than as pieces of parate disciplines. Similarly, the time of encouraging “inter”-ctoral action among policy-makers and politicians may be over, given the crisis of increasing health costs and inequities. Efforts to integrate and collaborate between areas of government, and indeed, between governments, will require a shared approach involving “trans”-ctoral action with concomitant supra-structures and process. Leadership and vision from the highest levels are required, and HiAP needs to become one of tho platform com-mitments against which government performance is judged. Only then will life be pumped into thirty years of rhetoric in the rvice of achieving some increasingly timely health goals.

REFERENCES

1.Ottawa Charter for Health Promotion, 1986. Available at:

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2.Epp J. Achieving Health for All: A Framework for Health Promotion. Ottawa,

ON: Ministry of Supply and Services Canada, 1986. Available at:

408REVUE CANADIENNE DE SANTÉ PUBLIQUE • VOL. 102, NO. 6 HEALTH IN ALL POLICIES

a/hcs-sss/pubs/system-regime/1986-frame-plan-pro-motion/index-eng.php (Accesd January 10, 2011).

3.Canada Health Act (R.S.C., 1985, c. C-6). Available at: laws-lois.jus-

4.Lalonde M. A New Perspective on the Health of Canadians. Ottawa: Ministry

of Supply and Services Canada, 1981. Available at: a/hcs-sss/com/fed/lalonde-eng.php (Accesd January 10, 2011).

5.Keon W, Pépin L. A Healthy, Productive Canada: A Determinant of Health

Approach. Ottawa: The Standing Senate Committee on Social Affairs, Science and Technology, 2009. Available at: a/40/2/parlbus/ commbus/nate/com-e/popu-e/rep-e/rephealth1jun09-e.pdf (Accesd January 10, 2011).