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

Ketan Shankardass,Goldameir Oneka,Patricia O’Campo,Faraz Vahid Shahidi,Carles Muntaner,Alix Freiler,Lauri Kokkinen,Ahmed M Bayoumi

doi:10.1186/s12961-018-0295-z

Abstract

BackgroundThere 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.MethodsOur 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.ResultsWe 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.ConclusionsThis 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.

Highlights

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)
To help other researchers learn from case studies of HiAP implementation, this article begins by providing a description of systems theory followed by a description of a system of 14 components within three subsystems of government, which we argue mainly explain implementation outcomes alongside some important extra-governmental influences
Case study: The implementation of Health 2015 in Finland Below, we demonstrate the value of using the systems framework of HiAP implementation to organise information about a particular policy issue and outcome in the implementation of Health 2015 in Finland

Summary

Introduction

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). 2), in which governance structures and processes are used to facilitate policy coordination in an evidence-informed manner, sometimes guided by explicit long-term strategies and goals [3] In this formulation, HiAP is not a specific approach (as presented more recently by WHO [4]), but rather a general concept that accommodates diverse initiatives, where “HiAP initiatives may include multiple programmes or projects that are fostered across multiple sectors and multiple levels of government either directly or indirectly related to the original policy commitment” As more governments have adopted HiAP approaches globally, there have been calls for greater monitoring to better understand how integrated governance can be used to meet health and equity objectives [4, 6,7,8] The need for such attention stems from multiple challenges. Since HiAP is a concept rather than a model, every HiAP initiative is uniquely designed and governed, and so it is challenging to understand how to translate studies of one case to others

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