In Centralized Health Systems, Much Is Left Out When Analyses of Local HiAP Strategies Are Limited to Public Administration; A Commentary on "A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland"

Abstract

We argue that the lessons drawn by Guglielmin and colleagues (2022), from the Health in All Policies (HiAP) approach in the municipality of Kuopio, are of limited use to centralised health systems. There is a need for research more attuned to the circumstances of local governments that have little power over the provision of health programmes; yet can address a range of determinants of population health. In these cases, adopting a state-centric perspective may fail to capture the role of other actors such as NGOs and local branches of state agencies. Evidence from France shows that centralised health systems can foster HiAP locally through political commitment and dedicated coordination staff whose role is to mobilise and support NGOs, inhabitants, and other local branches of regional and central governments. We highlight, as three important challenges, the issue of legitimacy, funding and positioning of the HiAP instrument in the local government structure.

Developing a Research Agenda for HiAP Implementation: A Response to the Recent Commentaries

“…We likewise agree with Breton and Le Bodo 2 that systems theory can help understand generative causality through identifying and analyzing the system of actors and the connections they create that can lead to emergent properties that mobilize new agents and resources for HiAP implementation. While the case study of Kuopio did not centre on a systems theory approach, we have contributed to the development of a systems level approach to HiAP implementation, 5 with a focus on understanding the relationships between key actors and resources across three sub-systems of government and a range of extra-governmental actors.…”

“…The three commentaries by Williams and Valentine, 1 Breton and Le Bodo, 2 and Amri and Bump, 3 written in response to our article, 4 raise important points that highlight key gaps and challenges in studying and evaluating Health in All Policies (HiAP) initiatives. We appreciate and agree with many points raised about the complexity of HiAP initiatives; the importance of studying the role of non-governmental actors involved in local HiAP initiatives; and the need for greater focus on issues of health equity.…”

“…Williams and Valentine 1 aptly point out that HiAP is a complex intervention, describing it as “support(ing) actors and actor-groupings, who do not behave in predictable linear patterns, to work across organizational hierarchies, cultures, and disciplines to generate improved solutions.” Breton and Le Bodo 2 also highlight that our analysis of HiAP implementation in Kuopio focused on the role of local state actors, which risks oversimplifying causal processes. Elsewhere, 5 and in our current work to examine five case studies of HiAP implementation at the local level in Ontario and Québec, 6 we include a focus on extra-governmental actors including from the private sector, third sector, and First Nations, as well as the influence of other government systems.…”

“…Elsewhere, 5 and in our current work to examine five case studies of HiAP implementation at the local level in Ontario and Québec, 6 we include a focus on extra-governmental actors including from the private sector, third sector, and First Nations, as well as the influence of other government systems. Nevertheless, Breton and Le Bodo 2 enrich the conversation on HiAP implementation by highlighting the essential role of dedicated coordination staff in some regions of France to facilitate contracts between Regional Health Agencies and local authorities to improve population health. While much of the scholarship on HiAP implementation focuses on political leaders and actors representing various policy sectors, this draws attention to the value of funding staff positions that make intersectoral coordination more feasible.…”