Source: WHO infographic available from:
http://www.euro.who.int/__data/assets/pdf_file/0007/319804/banner-health-SDG-era.pdf?ua=1
Figure 1. Health in the SDG era
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health is fast becoming a cornerstone of all national SDG implementation plans, and the challenge at hand is to create a new culture of government where health is mainstreamed.
The final goal is well described in the case study from Christchurch, New Zealand: “Having health as part of the conversations and having equity as a focus are now business as usual for councils to the point where they no longer recognise these topics as unusual.”
Adaptation and reinvention over time The case studies show how HiAP has been adapted and reinvented over time. Indeed the literature on wicked problems highlights the need for an opportunity-driven approach based on making decisions, doing experiments, launching pilot programs, testing prototypes and so on.3 First generation HiAP approaches have - over the last 10 years or so - had to be very adaptive, resilient and creative to respond to changing contexts, especially shifting political priorities. It has been easier for those with a clear legal or regulatory base, and reliable funding.
Today, as the SDGs provide the vision and the goals for action, we enter a new development phase of HiAP approaches: what might have been seen as the chaotic exception is turning out to be the way things are.
Many of the case studies in this book exemplify how the perspective on HiAP is changing - best documented perhaps by the pioneer country that has been pursuing HiAP since the 1970s.
Finland is in the process of developing a new approach which combines health, wellbeing and equity, and is beginning to use the expanded title of Health and Wellbeing in all Policies:
HWiAP. This precisely reflects the wording of SDG 3 for which Finland argued consistently during the SDG negotiations and makes it easier to refer to the targets and indicators developed under that SDG. The legitimacy and necessity for action is now drawn from both nationally and globally adopted goals that all countries have agreed to work towards.
This means that the framing of HiAP will need to be revisited in many instances. The Shanghai Declaration points out that HiAP stands for
exactly the type of transformative action called for by the 2030 agenda: an approach based on equity, cooperation and empowerment.4 The focus is on the broader societal transformations that benefit the poorest and can improve the wellbeing of society as a whole. Many of the examples in this book exemplify this reframing and show how HiAP activities are increasingly integral to overall government policy and therefore have the support of high-level decision-makers. As California did early on in its development of HiAP, the challenge is to integrate the promotion of health with overall societal goals such as increasing equity and planetary challenges, thus combining the various pillars of sustainability. As expressed in Figure 2 from Finland, the wellbeing of people can only be achieved if it is firmly grounded in securing the natural environment, and if all sectors of society contribute: the private sector, civil society and governments.
Framing: HiAP as societies for wellbeing and sustainability
Most HiAP work is framed in terms of how investments in health contribute to a more productive society, strengthen resilience and social cohesion, empower people and contribute to social capital, wellbeing and happiness.
Health also contributes significantly to the economy - it creates value for business to contribute to healthy communities, overcome gaps in equity, develop new industries around healthy products and services and low carbon.
Health is seen as a social and economic development goal requiring action from government, society and the private sector.
The case studies show that this applies to societies at all levels of development:
• In the Healthy China 2030 strategy, health is framed as a top priority to reach “a prosperous society, fulfil the SDGs and modernise
society”.
• The case study from Finland shows how HiAP has become integral to the Finnish Government program with “promoting wellbeing and health” as one of five overall objectives.
• The Californian Healthy Community Framework on which the state’s HiAP work is based also aims to integrate five priorities which address the key determinants of health: basic needs, environment, economic and social development, equity and social relationships.
• The Quebec Government has recently adopted a whole of government intersectoral Policy for Prevention in Health.
• The examples from Sudan, Surinam, Namibia and Zambia all position health as part of the national development plans.
HiAP strategies all recognise that investments in health can help lift people out of poverty and that the largest population health benefit is achieved by addressing the social determinants of health and ensuring and protecting people’s rights - no matter what their position in society, gender, sexual orientation, age or level of disability. More than in the past the combined actions on health
and environment are prioritised and the co-benefits between sectors are highlighted.
Transformation through highest level political action
Wicked problems are about people, stakeholders, vested interests and politics - and so are
the SDGs. Rather than be understood as a technocratic planning tool, HiAP is rediscovering its political dimension. The case studies reflect that increasingly health and wellbeing are the concern of the highest level of government. In California, an executive order by the Governor established the Health in All Policies Task Force and later legislation established the office of health equity, and in South Australia the support of the Office of the Premier and Cabinet was critical.
The case study from Christchurch underlines the same point at the city level. In Quebec HiAP is now supported by the Council of Ministers.
Figure 2. The sustainable well-being framework
Source: Reproduced from Hämäläinen T. (2013 ). Towards a Sustainable Well-being Society. Building blocks for a new socioeconomic model.
Helsinki: Sitra. Available from: http://rritrends.res-agora.eu/uploads/22/Towards_a_Sustainable_Wellbeing_Society.pdf. Page 5 (adapted from Eeva Hellström, Sustainable Economy Forum, not dated).
Natural Environment Public Sector Private
Sector
Civil Society
Well-being
SOCIA L SU
STA INA
BIL
ITY
ECOLO
GICAL SUSTAINABILITY C E
NO
OMIC SUSTAINABILITY
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The second generation case studies show that countries are now linking their policy goals to the 2030 agenda and are adopting national visions, strategies and action plans linked to the SDGs. These can run from 5 to 15 years, pushing beyond short-term political gains.
They have learned from the more seasoned approaches that highest level political support makes the difference and have the support of the SDG agenda to move in this direction. For example, Namibia has set the goal to adopt a national strategy for Health in All Policies which is coordinated in the Office of the Prime Minister and has strong links to the National Planning Commission.
A transformed Ministry of Health and health department
This SDG related change in perspective of how the promotion of health contributes to other social goals requires a transformed Ministry of Health (MOH) which works relentlessly to integrate investment in health with the logic of other policies and programs. Ministries of health, health agencies and organisations have a key role in advocating, mediating and enabling health. This is reinforced if this work is strengthened by legislation, for example through public health acts. In Québec the act adopted in 2001 required “all government sectors to ensure that their laws and regulations do not cause any negative impact on the population’s health”.
The critical issue of such laws is to establish the legitimacy of the MOH or other health agencies to operate outside of the boundaries of their sector. The implementation of the cross-sectoral and multidisciplinary challenges calls for adaptable and integrative systems capabilities as part of the overall public health system - this has not always been the case as some case studies show. Indeed the South Australian case study indicates an extraordinary story of survival in an environment that cut support to health promotion programs drastically.
Transformation through policy coherence Problems cannot be treated in silos. The goal of Health in All Policies described in the case studies is increased policy coherence. As Namibia outlines the general goal is that a HiAP approach should systematically take into account the health implications of decisions, seek synergies and avoid harmful health impacts on health and health equity. California’s Task Force acts as a “collaborative, multiagency body charged with promoting health, equity and environmental sustainability”. This is done in a multitude of creative ways as the case studies show: working groups, platforms, taskforces, committees, tandems and agreements between sectors using the South Australian health lens approach. This diversity underlines how contextually dependent the mechanisms are.
There is in general much lip service being paid to policy coherence. However, this does not always translate into practice. In the end politics may matter more than policy commitments. More efforts are needed to facilitate investment to support implementation of these policies. In the literature it is suggested that these factors be addressed by applying social and organisational modelling. A HiAP strategy would then aim to do three things in the move towards policy coherence: define the contextual environment and the extent to which that can be influenced or changed; define those actions which it can control within its own strategic space; and define the transactional environment where it aims to affect change together with the other actors in the space. It is in the transactional environment where ‘out of the box’ thinking is developed and where policy coherence is constructed as a dynamic process.5
Transformation through participatory governance
Social mobilisation, high levels of health literacy and community participation, especially
of vulnerable groups such as indigenous people is one of the most critical governance challenges to implement the SDGs and to ensure sustainability. The case study that has most to offer in this regard is the Thai mechanism of the National Health Assembly.
No other HiAP approach is so participatory.
Here is probably one of the biggest challenges of HiAP for second generation programs: how to involve not only other sectors but a broader range of stakeholders and representatives of the public at large. The Shanghai Declaration also draws attention to the role of health literacy in empowering individual citizens and enabling their engagement in decision-making. A high level of health literacy of decision-makers also supports their commitment to health impact, co-benefits and effective action on the determinants of health.
Knowledge and data transformation Reporting and monitoring is critical for HiAP approaches, including routine reporting and health impact assessments. For example, Namibia plans a determinants of health of the nation report every two years. Where HiAP becomes embedded in national policy, such as China, then routine statistical systems will need to incorporate reporting on equity and social determinants of health. Enormous potential lies in sharing knowledge and in using data in new ways to better plan: for public health, for better cities, for better health care services. A new ethics on issues of privacy, confidentiality and ownership is called for in relation to tracking determinants and inequities.
Capacity building to work in new ways The rapidly changing environment and the increasing need for joined-up policy requires continuous capacity development for staff engaged in health promotion. As governments, businesses and civil society are challenged to work together to achieve the Sustainable
Development Agenda and work in HiAP, new skills are required of all actors involved in
generating health and wellbeing. The trajectories of the older generations of HiAP clearly point to the need for different skill sets during the
‘start up’ phase and the ‘maintenance phase’.
Thinking about, and incorporating practise to support sustainability of HiAP is also required from the outset.