The implementation of Health in All Policies initiatives: a systems framework for government action

Abstract

Background: There has been a renewed interest in broadening the research agenda in health promotion to include action on the structural determinants of health, including a focus on the implementation of Health in All Policies (HiAP). Governments that use HiAP face the challenge of instituting governance structures and processes to facilitate policy coordination in an evidence-informed manner. Due to the complexity of government institutions and the policy process, systems theory has been proposed as a tool for evaluating the implementation of HiAP. Methods: Our multiple case study research programme (HiAP Analysis using Realist Methods On International Case Studies -HARMONICS) has relied on systems theory and realist methods to make sense of how and why the practices of policy-makers (including politicians and civil servants) from specific institutional environments (policy sectors) has either facilitated or hindered the implementation of HiAP. Herein, we present a systems framework for the implementation of HiAP based on our experience and empirical findings in studying this process. Results: We describe a system of 14 components within three subsystems of government. Subsystems include the executive (heads of state and their appointed political elites), intersectoral (the milieu of policy-makers and experts working with governance structures related to HiAP) and intrasectoral (policy-makers within policy sectors). Here, HiAP implementation is a process involving interactions between subsystems and their components that leads to the emergence of implementation outcomes, as well as effects on the system components themselves. We also describe the influence of extra-governmental systems, including (but not limited to) the academic sector, third sector, private sector and intergovernmental sector. Finally, we present a case study that applies this framework to understand the implementation of HiAP -the Health 2015 Strategy -in Finland, from 2001 onward. Conclusions: This framework is useful for helping to explain how, why and under what circumstances HiAP has been successfully and unsuccessfully implemented in a sustainable manner. It serves as a tool for researchers to study this process, and for policy-makers and other public health actors to manage this process.

Qualitative process evaluation from a complex systems perspective: A systematic review and framework for public health evaluators

“…The in-depth descriptions were written to give clear examples of how these approaches have been applied in practice. A range of public health topics were represented in the sample, including social work [ 43 – 45 ], school health [ 41 , 46 – 50 ], workplace health [ 51 , 52 ], sexual health [ 48 , 53 , 54 ], health equity policy [ 55 , 56 ], urban planning [ 57 , 58 ], substance use [ 53 , 56 , 59 – 61 ], child development [ 62 ], public–private partnerships [ 63 ], community empowerment and transformation [ 42 , 64 ], and violence prevention [ 65 ]. The studies were conducted in 13 countries, which included 9 high-income and 4 middle-income settings: Australia [ 51 , 52 , 57 , 65 ], Brazil [ 55 ], Chile [ 62 ], El Salvador [ 54 ], Finland [ 56 ], India [ 62 ], Israel [ 43 , 44 ], the Netherlands [ 46 , 47 , 58 ], New Zealand [ 50 ], South Africa [ 48 , 62 ], Sweden [ 59 ], the United Kingdom [ 42 , 49 , 60 , 61 , 63 , 64 , …”

“…This included existing frameworks such as the Cynefin framework [ 48 ], Consolidated Framework for Implementation Research [ 59 ], a complex adaptive systems framework [ 54 , 62 ], and the socioecological model [ 41 ]. Other evaluations featured bespoke frameworks for analysis, including ones that focused on the role of critical events in an intervention’s trajectory [ 55 ], a systems framework focusing on governmental subsystems [ 56 ], and a framework that was used to identify and categorize different types of “by-effects” or unintended consequences [ 58 ].…”

Autonomous Vehicles and Public Health

“…AV policies and regulations should be analyzed, debated, and implemented in advance of the full introduction of AVs to the market. A "health in all policies" approach will help minimize the health risks related to AVs and maximize their possible benefits (71). Public health practitioners should lead intersectoral groups to introduce health vision into the AV projections.…”

"First, Do No Harm": Have the Health Impacts of Government Bills on Tax Legislation Been Assessed in Finland?

“…This does not mean that HIAs would automatically and immediately lead to changes being made in the policies, as recent evidence suggests that even when the health impacts have been assessed as negative and large, other impacts, such as positive economic ones, may have carried more weight for decision making in the Finnish Parliament. 11 , 12 However, in the longer term a mandate specifying HIA of structural determinants of health should help to increase the transparency of policy processes and make the policy-makers more responsible for their decisions. .…”

“…As Finland is one of the rare countries where HIAs are mandated for national policy proposals, there is not much previous research in this area despite the critical role taxation and other key public policy domains play in population health through a wide range of social determinants of health. Therefore, as more countries currently adopt a Health in All Policies strategy and institutionalize related techniques such as HIAs, 12 there is a great need for researchers to understand the importance of HIAs for different public policy domains, to gain experience in the focus of HIA on downstream and upstream determinants of health, as well as to ultimately use science to achieve greater government transparency in taking health into account in all policies.…”