Health In All Policies Approach Research Articles

Health Impact Assessment (HIA): a tool to drive health in all policies?

Abstract Health Impact Assessment (HIA) is often promoted as a tool to implement ‘health in all policies’ and sustainable development approaches to improve health and equity outcomes. However, is this truly the case? Currently global HIA practice is variable. This paper shares learning from the development and implementation of HIA in Wales to date to understand how HIA has been, and can be, used to inform policies and decisions and reduce health inequalities. The research investigated if, and how, HIA can be used as a tool to mobilise HiAP in reality. It followed a mixed methodological approach and investigated the contribution of HIA to practically advancing HiAP viewed through the lens of Wales and internationally. Primary and secondary evidence and statistics were collected and analysed. A literature review, stakeholder interviews, online statistical questionnaires and case studies were conducted. Thematic and content analysis techniques used. Findings include the importance of conceptual considerations i.e. the perspective on health - social determinant an equity or environmental determinant driven - taken by those carrying out or commissioning a HIA; the importance of centres of expertise to learn from; and practical considerations such as the political and regulatory environment, workforce and organisational knowledge and capacity. Wales has a dedicated expert HIA Unit, an enabling political environment and has led to HIA influencing policies and plans over 20 years. It has transferrable learning for other nations and the research including the online survey has been replicated by others, led to collaborations with nations such as Portugal and contributed to the reviewed literature by providing case studies on a topics like climate change which have influenced decision makers. Tangible ways forward for policy makers, researchers and academics include the need to develop more cross collaboration and fill gaps in the evidence i.e. on institutionalisation of HIA. Key messages • HIA is a excellent process to drive Health in all policies approaches. • HIA needs an enabling environment and workforce support such as that in Wales to thrive.

Working on new applications: Use of economic evaluation in burden of disease estimates

Abstract Burden of disease (BoD) analyses provide policy-makers with useful evidence to prioritise policy responses to major public health threats. Increasingly, however, epidemiological data alone is not considered as sufficient to inform decisions, particularly when funding is allocated within a single government approach and different sectors compete for a larger share of the overall budget. Similarly, other funders, such as charities and foundations, may want to prioritise budget allocation between health and non-health objectives. In all these cases, traditional BoD analyses need to be complemented by economic evaluations. In its simplest form, the economic component may mean adding an assessment of the healthcare costs caused by the diseases in the study. A more comprehensive, though still with limitations, approach is to use monetary values to measure the extent to which individuals are willing to exchange their income - which can be spent on other things - for the health outcomes they experience. Finally, in its most advanced and comprehensive form, analyses can include assessments of a number of relevant dimensions, such as those in the OECD’s Better Life Index. The latter approach is also consistent with, and its results support the implementation of, a health in all policies approach. This presentation will look at traditional and innovative approaches that can be used to add an economic dimension to BoD analyses. After introducing the rationale and key methodological issues of each approach, the presentation will discuss the advantages and disadvantages of each methodology and will identify areas where their use can be beneficial in guiding the decision-making process. Examples of the use of these methodologies in real-world analyses will also be presented to support the theoretical part of the discussion.

Gaining influence: Developing a Healthy Public Policy Unit at Vancouver Coastal Health.

Regional Public Health Unit (Office of the Chief MHO, Vancouver Coastal Health Authority, BC, Canada). Recognizing the need to invest resources that strategically move public health work "upstream" where policies and investments can shape the determinants of health, the Office of the Chief MHO for Vancouver Coastal Health embarked on a process in 2019 to develop a population health team designed to engage in Healthy Public Policy (HPP) and Health in All Policies (HiAP) approaches to health promotion. The mission and design of this unit was informed by internal and external research and engagement which continued even through the COVID-19 pandemic. Inthe fall of 2022, this new unit, the first of its kind in British Columbia, was launched. In 2023, it embarked on strategic planning, engaged in key public policy processes, and implemented priority areas of work to help advance healthy public policy in the region, including the development of processes, tools, and practices to support a more systematic and rigorous approach to this emerging area of public health practice. The creation of this new Healthy Public Policy Unit invites discussion within Canada's public health community on the issue of resource allocation to support upstream interventions seeking to build the capacity and effectiveness of HPP and HiAP approaches.

Enablers and obstacles for designing and implementing intersectoral health policies: Lessons from Mexico

AbstractBackgroundThis study analyzes how national intersectoral public policy experiences have been adopted and implemented using a Health in All Policies (HiAP) approach in the past two decades. It seeks to provide evidence on enabling factors that triggered three effective intersectoral public policies to improve population health in Mexico by improving nutritional, educational, and healthcare access conditions, reducing road traffic injuries, and addressing obesogenic feeding practices.MethodsWe followed a qualitative approach to analyze the three intersectoral public policies selected as case studies. First, we designed an analytical framework to assess how intersectoral public policies are adopted, implemented, and sustained. The proposed framework is based on peer‐reviewed articles and gray public policy literature. Second, we used information from eleven semi‐structured interviews with key stakeholders conducted in previous research to identify more specific enablers and barriers of the three intersectoral policies selected according to predefined analytical categories used in the questionnaire.ResultsThe analysis showed three overall key findings. First, sound empirical evidence is essential for adopting a HiAP approach. Second, effective intersectoral mechanisms enhance implementation feasibility. Third, results‐based monitoring and evaluation contribute to the continuity of the analyzed intersectoral public policies. Finally, political support is needed throughout the policy process to maintain governance capacity and deliver results.ConclusionWe drew five global policy lessons that may be applicable in similar public policy settings in other countries. First, both technical and political enablers help set the intersectoral agenda. Second, effective communication is instrumental in convincing all stakeholders to address public health‐related policy issues. Third, political support at the highest level possible and the federal government's capacity are essential to implement sound policies. Fourth, several enablers exist for enhancing collaboration between ministries during implementation. Finally, monitoring and evaluation results are necessary for sustaining intersectoral policies beyond administrations.

Implementation of Preventive Care in the setting of primary care: opportunities, hurdles and policy needs for integration of Preventive Care in the daily practice of primary care practitioners.

In Flanders, as in the entire industrialized world, the population is eldering and chronic conditions and comorbidities are increasing importantly. Today, non-communicable diseases (NCD’s) have an important negative impact on the quality of life and represent the most important cause of premature and/ or preventable death. Moreover, they also put an enormous burden on the health care system, in terms of need for health professionals, procedures and medicines, short and long term care institutions as well as on the affordability of the health care system. The knowledge that the majority of these NCD’s can be avoided by prevention, through a healthy lifestyle and early detection, calls for more emphasis on and means for preventive health care.
 Traditionally and still today, the primary and secondary care practice in Flanders is focused on curation and preventive health care is mainly practiced by others, such as school health services and Maternal and child health services. The fundamental principles of curative and preventive care are very different. Curative care is based on an individual approach and is driven by individual demands. However preventive health care is mainly based on population health management and driven by, often not expressed, population needs.
 When it comes to implementation of preventive care, the WHO advocates a Health in all Policies approach, in which preventive care is implemented in all life settings surrounding the citizen, in order to achieve an integrated preventive care policy that is supported by all policy domains and is part of daily life. One of these settings is health care.
 In this workshop we want to exchange experiences on implementation of preventive health care into primary healthcare and to explore the opportunities, hurdles and policy needs to come to a successful adoption of preventive health care in the setting of primary healthcare. To introduce the debate, the session will start with two short presentations of 10-15 minutes in which experiences in two different health care systems, i.e. a national health care system and a predominant private health care system, are shared with the participants.

Effects of the Implementation of Transport-Driven Poverty Alleviation Policy on Health Care-Seeking Behavior and Medical Expenditure Among Older People in Rural Areas: Quasi-Experimental Study.

Improving the rural residents' accessibility to and affordability of health care is recognized as a common target globally. The Health in All Policies approach, from the Declaration of Helsinki to the United Nations' Decade Of Healthy Ageing, strengthened the far-reaching effect of large-scale public policies on health care-seeking behavior; however, the effects of national transport policy on health care-seeking behavior is unclear. This quasi-experimental study aimed to examine the effects of the implementation of transport-driven poverty alleviation (TPA) policy on health care-seeking behavior and medical expenditure among older adults in rural areas and the mechanism underlying these effects. We designed a quasi-experiment to estimate the effects of TPA policy implementation on health care-seeking behavior and medical expenditure among older adults in rural areas through a difference-in-differences (DID) analysis based on data from the China Health and Retirement Longitudinal Study in 2011, 2013, 2015, and 2018. The underlying mechanism was analyzed and effect modification patterns were further investigated by poor households, health status, and age. Our findings validated a positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas. After the implementation of TPA policy, the number of inpatient visits increased by annually 0.35 times per person, outpatient medical expenditure increased by 192% per month, and inpatient medical expenditure increased by 57% annually compared with those of older adults in rural areas without the implementation of TPA policy. Further, there was a significant modification effect, with a positive effect among poor households, healthier older adults, and those aged 60-80 years. Additionally, the policy improved the patients' capabilities to seek long-distance care (β=23.16, 95% CI -0.99 to 45.31) and high-level hospitals (β=.08, 95% CI -0.02 to 0.13), and increased individual income to acquire more medical services (β=4.57, 95% CI -4.46 to 4.68). These findings validate the positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas; however, the medical expenditure incurred was also high. Concerted efforts are needed to address health care-seeking dilemmas in rural areas, and attention must be paid to curbing medical expenditure growth for older adults in rural areas during TPA policy implementation.

4.G. Round table: Environmental stressors on health economics and policies – challenges and pitfalls

Abstract Health impact assessments (HIA) provide decision-makers with sound information about the health implications of policies or programmes and projects. Using an economic lens to perform HIA and to study policies to be implemented, can be a daunting task as there are many challenges can hamper its performance. Data scarcity and difficult access to it, is frequently a challenge when analysing health policies, emphasizing the importance of methods for collecting primary data. Additionally, something even rarer is to have data stratified by socioeconomic variables. This is of particular importance as it is the way of evaluating the impact of policies on equity of the health systems. Information on both the costs and outcomes of the interventions are essential. However, the transferability of this information for other contexts or countries can be hampered by many specificities in the different sides of the equations, such as the heterogeneity of unit prices in different countries. Often relying on cost-benefit analysis, HIA exercise encompass with the two processes in terms of costing, i.e. assessing the input costs of a policy and monetizing the health outcomes or losses on outcomes. Effectiveness of a policy mainly concerns with long term impacts of health, but economic evaluation might fail to monetise the exact effects with pros and cons. In fact, with the enormous options on mathematical modeling providing a clear picture of the impact of health policies, might diverge the researchers or decision makers for a clear and straight pathway towards nvironmental and health governance. Specifically, to the environmental risk factors to health, these also lead to an extra layer or step as a linkage between exposure to the risk factor and the subsequent impact on health might be faced later. Interministerial work is thus essential in order to overcome specific problems on access and data quality. In this round table, different perspectives will be given on the challenges of performing an environmental HIA, with some practical examples. From data to knowledge translation, we will focus on specific use cases to describe mental health systems. This roundtable was supported by EUPHA Public Health Economics, EUPHA Health Impact Assessment and EUPHA Environment and Health sections, as well as supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia,I.P., within CINTESIS, R&D Unit (reference UIDP/4255/2020). Key messages • Data availability and access are still among the main challenges to overcome when performing a health impact assessment. • A Health in All Policies approach, the best option for evaluating environmental policies, highlight the importance of interministerial work. Speakers/Panelists Marco Martuzzi Istituto Superiore di Sanità, Rome, Italy Brecht Devleesschauwer Sciensano, Brussels, Belgium Marija Jevtic University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia Vlatka Matkovic Health & Environment Alliance, Brussels, Belgium

Health inequalities of LGBT persons in Switzerland – Results from the first national LGBT health study

Abstract Background Internationally, there is evidence that lesbian, gay, bisexual and transgender persons (LGBT persons) have poorer health outcomes than the heterosexual or cisgender population. In addition, LGBT populations face more frequent and unique healthcare access barriers. Barriers to healthcare among LGBT persons in Switzerland remained undocumented until recently, when the Swiss Federal Council mandated a report describing the health and healthcare access of LGBT persons, and related health inequalities. Methods Two data sets were included in analyses: (1) two waves of the representative Swiss Health Survey (SHS 2012, 2017) n = 29,793, ages 16 to 74, including 858 LGB persons, and (2) data from a non-representative national online survey (May to July 2021), including 1,542 LGB cisgender and 522 transgender persons, ages 15 to 81. Data were analyzed using descriptive and inferential statistics (e.g. binary logistic regression), controlling for potential confounding factors (e.g. year of study, age), using the Health Equity Promotion Model as a conceptual framework. Results The most significant areas of health inequalities across the groups of interest were mental health, experienced discrimination and violence, healthcare access barriers, substance use, and sexual health. For example, LGB persons experienced significantly higher rates of depression (16.0% vs. 7.4%; p<.001) and suicide attempts (11.0% vs. 3.3%; p<.001) compared to the heterosexual population. Additionally, LGB persons abstained from seeking medical care significantly more often than heterosexual persons (16.2% vs. 6.9%, respectively) due to a lack of trust in the healthcare system. Conclusions Besides targeted action in the identified (health) areas, a Health in All Policies Approach is needed to improve the lives and health of LGBT people in Switzerland by diminishing stigmatization and discrimination, and by implementing LGBT inclusive and specific protocols in healthcare and other settings.

Public health practitioners as policy advocates: skills, attributes and development needs.

Effecting policy change is a key strategy in tackling wider determinants of health. In England, public health sits within Local Authorities (LAs) and responsibility for ensuring health is considered across directorates increasingly falls to public health practitioners. While international professional standards expect competence in understanding policy processes, the advocacy role has been under-explored. This paper explores the professional skills, role characteristics and learning needs of practitioners advocating for the restriction of advertising high-fat, salt and sugar products in a region of England. A series of three interviews were conducted at three time points over 10 months with policy advocates leading this policy change from four LAs. Three focus groups were also held with 12 public health advocates from 10 LAs at the end of the 10-month period of data collection. Data were transcribed and analysed retroductively. Data showed that practitioners felt inexperienced as policy advocates and saw this work as different from other public health approaches. Successful advocates required interpersonal skills, knowledge of policy-making and local governance, determination, resilience, confidence, belief in their work's value and leadership. These skills were difficult to acquire through formal education, but advocacy training, mentorship and role modelling were seen as important for professional development. To successfully implement a Health in all Policies approach and address wider determinants of health, public health practitioners need to be equipped and supported as policy advocates. The advocacy role and the complex skills required need to be more fully understood by the public health profession and prioritized within workforce development at both local and national levels.

O.4.4-4 SPORTLAND HESSEN bewegt as an innovative health enhancing physical activity program at state level based on a Health in All Policies (HiAP) approach

Abstract Purpose The lack of physical activity in our daily lives and the associated health consequences are also a far-reaching health problem in Hesse, which has been amplified by the corona pandemic. To counteract this, Hesse set up its state program “SPORTLAND HESSEN bewegt”. The aim is to offer the Hessian population a more diverse and better coordinated range of physical activity promotion measures across all ages. This includes raising awareness of the multiple benefits of promoting physical activity, increasing the intersectoral cooperation between all relevant actors, linking the numerous existing efforts to promote physical activity in profitable manner and expanding programs and structures across all ages. The state program, which sees its mission as a challenge for society as a whole, is primarily targeting all relevant multipliers who can make Hessen more active: from politics to providers of physical activity programs in the municipalities. Not only sports organizations play a central role here, but also players from the fields of education, urban development, transport, health, environment and many more. Project description To this date five state ministries, the state sports association as well as the state association for health promotion are involved as well as many other partners. For this purpose, a structure was created that enables all stakeholders to work together, taking into account the different age groups. As think tanks for the development of measures to promote physical activity, interministerial and intersectoral working groups have been initiated. In addition, coordinators for the promotion of physical activity at municipal level are being established, funding programs for sport clubs were set up and exercise checks are being carried out at primary schools. Conclusions As the WHO states in their global action plan on physical activity, increasing physical activity requires a systems-based approach. However, there is no blueprint for such a HiAP approach for the promotion of physical activity. State government, organized sport and many other partners are pulling together to motivate citizens to adopt a more active lifestyle. By working together, the stakeholders and citizens will hopefully benefit of the synergies and further innovative measures and approaches can be established.

Canine Support Program: Student perceptions and preferences at a regional university and implications for health, well-being, and student support enhancements.

Canine Support Programs (CSPs) are a potential solution to growing university student support demands. While current studies focus on the impacts of CSPs, there is limited understanding of the views and expectations of tertiary students about CSPs. This study explored the perceptions and preferences of students in an Australian regional university about CSPs. A questionnaire with multiple choice and open-ended questions surveyed residential students' perspectives about CSP. Data were analysed using descriptive statistical tests and thematic analysis for open responses. Majority (98%) of participants (sample n = 48) would support a CSP on campus. Frequent, small-group interactions of ≥15 min involving physical contact were preferred. Dog disposition, welfare-trained handlers, and veterinary certification were important aspects of program safety. Participants strongly agreed a CSP would improve mental health and well-being, relieve stress, reduce feelings of homesickness, provide support, comfort, and enable social interactions. There is strong support among the study population for CSP to be established on campus. This study supports earlier research that CSP has benefit potential for new, stressed, and/or students who love dogs. The preferences of students should inform program design to enhance utility and impact. This aligns with Health Promoting Universities and College's Okanagan Charter principle of 'engaging student voices'. More institutional awareness and support for CSPs will be necessary for integration. SO WHAT?: This study reveals the need for tailored and creative student support beyond traditional offerings including those that focus on student well-being and social initiatives. CSPs can be utilised as an advocate, enabler, and medium for mental health promotion action and well-being support for tertiary students; thereby, contributing to the 'Health Promoting University' agenda in Australia. It also reinforces the need for a Health in All Policies approach to be incorporated into our tertiary education sector. Future actions should focus on improving institutional awareness, support, and sector implementation.

Clinical Leadership and Integration of Triple Bottom Line for Planetary Health

The accelerating global concern of climate change and its link with human health requires sustainability to be a crucial part of healthcare quality. The protection of planetary health in the context of ecological and social determinants of health require the integration of all aspects of health services including the professionals, management, and administration. Clinical health professionals particularly hold a critical position in this scenario, as they are mandated to protect individuals and communities from diseases caused or accelerated by environmental factors. Therefore, to combat the negative impacts of climate change on human health, the trusted voice of clinicians needs to be raised for communicating climate risks and solutions to patients, the public, and policymakers.
 Medical colleges’ curricula and continuing education programs require an alignment of climate and health education. This will equip future and current health professionals with skills for planetary health, regardless of their area of health focus. Clinical teaching and training with an updated medical education curriculum focusing on prevention; self-care; patient empowerment; lean service delivery such as community-based interventions; minimizing waste of medications and consumables, and low carbon emission alternatives is imperative to health service’s contribution in enhancing the quality of ecological sustainability.
 It has been documented that if the healthcare sector is ranked as a country, it would be the 5th largest CO2 emitter in the world with 4.4% global net emissions of greenhouse gases.1 The WHO has recently reported that 60% of healthcare facilities in the global south are ill equipped to handle existing waste loads. The healthcare community, clinicians, and hospital management are well-placed to play a vital role as change agents with Health in All Policies approach by protecting health during the current climate crises. An eco-friendly, equitable, interprofessional, and transdisciplinary approach is required to create a resilient healthcare sector that works harmoniously with nature while coping with increasing disease burdens and challenges to healthcare infrastructure.
 The triple bottom line is a holistic framework that helps organizations consider the environmental, social, and economic costs of their actions.2 In a healthcare setting, triple bottom line incorporates environmental and social impacts with patient-based outcomes and financial costs to measure the sustainability of healthcare interventions and services.2 It is an approach to reduce the adverse effects of healthcare delivery on the environment by incorporating improved sustainable quality and resource stewardship. The overall sustainable value is measured when the patient-based outcomes comprising utilization of a system, service, or process in healthcare are weighed against the “planet, people, and profit”.
 In conclusion, embedding sustainability principles, core knowledge, and practice in health professional expertise; the voice of clinicians in advocacy and policy to minimize healthcare sector greenhouse gases and ecologic footprint; and cross-sectoral solutions to the climate crisis are the only way forward for sustainable healthcare and the planet.
 Editor-in-Chief

An Aboriginal-led consortium approach to chronic disease action for health equity and holistic wellbeing.

The Wellbeing Economy, which places human and ecological wellbeing at the centre of policy making, aligns with holistic Aboriginal and Torres Strait Islander conceptualisations of health and wellbeing. In order to address chronic diseases in South Australian Aboriginal and Torres Strait Islander populations, the South Australian Aboriginal Chronic Disease Consortium (Consortium) is fostering action in ways that align both with the Wellbeing Economy and with Health in All Policies (HiAP) approaches. In June 2017, the Consortium was established as a collaborative partnership between government and non-government organisations, researchers, Aboriginal organisations and communities to lead the effective implementation of three state-wide chronic disease plans. A coordinating centre was funded to support and progress the work of the Consortium. During its first 5 years, the Consortium has developed a foundation for sustained system reform through partnering with stakeholders, leading projects and initiatives, advocating for key priorities, leveraging existing infrastructure and funding, supporting services, and coordinating delivery of priority actions using innovative approaches. Through the Consortium governance structure, Aboriginal and Torres Strait Islander community members, policy actors, service providers and researchers oversee, drive, influence and support the implementation of priority action initiatives. Sustained funding, competing priorities of partner organisations and project evaluation are constant challenges. SO WHAT?: A consortium approach provides direction and shared priorities, which foster collaboration across and between organisations, service providers and the Aboriginal community. Aligning with HiAP approaches and the Wellbeing Economy, it harnesses knowledge, networks and partnerships that support project implementation and reduce duplication.

How can Health in All Policies approaches support the transition to the well-being economy?

Health in All Policies approaches support the integration of health considerations into the policies of traditionally siloed governance systems. These siloed systems are often ignorant of the fact that health is created outside of the health system and starts long before you see a health professional. Thus, the purpose of Health in All Policies approaches is to raise the importance of the broad-based impacts on health from these public policies and to implement healthy public policy that delivers human rights for all. This approach requires significant adjustments to current economic and social policy settings. A well-being economy similarly aspires to create policy incentives that increase the importance of social and non-monetized outcomes, such as increased social cohesion environmental sustainability and health. These outcomes can evolve deliberately alongside economic benefits and are impacted by economic and market activities. The principles and functions underpinning Health in All Policies approaches, such as joined-up policy making can be helpful to transition towards a well-being economy. Governments will need to move beyond the currently held principle of "economic growth and profit above all else" if countries are to tackle growing societal inequity and catastrophic climate changes. Rapid digitization and globalization have further entrenched the focus on monetary economic outcomes rather than other aspects of human welfare. This has created an increasingly difficult context within which to prioritize social policies and efforts aimed to achieve primarily social and not profit-oriented goals. In the face of this larger context, alone, Health in All Policies approaches will not bring about the needed transformation to achieve healthy populations and economic transition. However, Health in All Policies approaches do offer lessons and a rationale that is aligned with, and can support the transition to, a well-being economy. Transforming current economic approaches to a well-being economy is imperative to achieve equitable population health, social security and climate sustainability.

The economics of the wellbeing economy: Understanding heterodox economics for health-in-all-policies and co-benefits.

The "wellbeing economy" represents a significant departure from the orthodox, neoclassical economic model of rational, utility-maximising individuals embedded in a growth economy. Emerging approaches to the wellbeing economy draw heavily upon insights from a range of heterodox schools of economic thought; these schools differ in many respects, but all share the central common insight that the economy is best conceived as a social provisioning system for humanity's needs. This narrative review introduces and summarises key dimensions of a number of these heterodox economic approaches, all of which have had or are likely to have significant implications for wellbeing economics. Their relationship with wellbeing and their resulting approaches to public policy and the Health-in-All Policies (HiAP) approach is described and explored. The schools of heterodox economic thought which have had the most impact on the development of approaches to the "wellbeing economy" include ecological economics (including both post-growth and degrowth economics), feminist economics, and modern monetary theory. Recent developments in the economics of inequality and institutional economics have also been of significance. Yet HiAP approaches represent an attempt to incorporate consideration of health consequences within public policy processes inside the neoclassical economics paradigm, reflecting the reality that social and economic forces are typically the most important determinants of health. WHO's new Health For All approach draws much more directly on the heterodox economics that underpins wellbeing economy thinking. Wellbeing economics offers many attractive features for HiAP-but may not achieve its full potential within conventional economic policy paradigms. Calls to replace cost-benefit analysis with "co-benefit" analysis are attractive, but face strong practical obstacles. Meanwhile, strong countervailing forces and interests might still thwart achieving the broader goals of wellbeing economics. SO WHAT?: Operationalising "wellbeing economy" thinking requires a clear understanding of heterodox economics, and how they can be incorporated into more formal economic analysis. It remains to be seen if HiAP is the right tool by which to implement the new Health For All approach.

"Health in All Policies" in Norwegian municipalities-Dilemmas and lack of legitimacy and capacity.

According to the Health in All Policies (HiAP) approach, public health work in Norway is regarded as a multi-actor collaboration based on planning and partnership for the purpose of enabling people to increase their control over their health and its determinants. HiAP builds largely on the governance and communicative turn in the public sector and thus exists in the shadow of a vertical government structure with sectors, silos and a chain of command. In practice, HiAP challenges the established way of thinking and acting in the silos and tries to create a more holistic understanding and handling of problems and needs. In order to successfully involve different sectors and government levels in this work, HiAP requires strong democratic legitimacy and institutional capacity. In this article, we discuss the empirical research data on the HiAP approach in Norway within the context of theory on collaborative planning processes and legitimising political capacity to act. Our research question is whether the HiAP approach in Norwegian municipalities have sufficient democratic legitimacy and institutional capacity to achieve the purpose of public health work. In general, we find that HIAP as practised in Norwegian municipalities does not function as a complete political legitimising and capacity building process. The practice contains several dilemmas, and there is a need to distinguish between different forms of legitimacy and capacity.

Public health partner authorities-How a health in all policies approach could support the development of a wellbeing economy.

Collaboration and partnerships across sectors are critical to the realisation of a wellbeing economy. Wellbeing SA-a government agency in South Australia-utilises a partnership mechanism under the state's public health legislation to achieve collaborative action for improved population health and wellbeing: Public Health Partner Authorities (PHPAs). The establishment and implementation of PHPAs draws strongly on the principles and practices of South Australia's Health in All Policies (HiAP) approach. This includes the utilisation of cross-sectoral partnerships to facilitate the implementation of co-design and co-benefits principles to deliver policies that support improved population health and wellbeing, while simultaneously delivering other societal benefits. Partnerships also facilitate the sharing of knowledge and resources, and the creation of joint solutions to complex policy issues. PHPAs have been reported to offer a valuable, evidence-based and practical mechanism for embedding key concepts of wellbeing into the policies, practices and programs of other sectors, and provide the potential as one important tool for the formation of a wellbeing economy. The achievement of a wellbeing economy is dependent on collaboration within and between sectors, and through strong community engagement. Developing a joint and inclusive understanding of wellbeing and its importance as a societal goal is critical, and can only be achieved through collaborative approaches. The implementation of PHPAs in South Australia has demonstrated the importance of partnerships to address complex issues across sectors, and has identified key elements to successful partnerships. SO WHAT?: South Australia's experience in implementing PHPAs and HiAP has demonstrated how health promotion practice, policy and research that incorporate successful partnerships can support high quality, effective intersectoral collaboration for the benefit of citizens, including some lessons that may be worth considering in the development and realisation of a wellbeing economy.

Urbanization and the Future of Population Health.

Policy Points Cities, which are where the majority of the world's population lives today, directly and indirectly shape human health and well-being. Urban health research, policy, and practice are increasingly using a systems science approach to address the upstream and downstream drivers of health in cities, which include social and environmental factors, features of the built environment, conditions of living, and health care resources. To guide future scholarship and policy, we propose an urban health agenda for 2050 focused on revitalizing the sanitation movement, integrating data, scaling best practices, adopting the Health in All Policies approach, and addressing intraurban health inequities.

Where Is Equity in HiAP? Comment 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".

Health equity is no longer a central feature of Health in All Policies (HiAP) approaches despite its presence in select definitions of HiAP. In other words, HiAP is not just about considering health, but also health equity. But as HiAP has become more mainstream, its success around health equity has been muted and largely non-existent. Given the normative underpinning and centrality of equity in HiAP, equity should be better considered in HiAP and particularly when considering what 'successful' implementation may look like. Raising health on the radar of policy-makers is not mutually exclusive from considering equity. Taking an incremental approach to considering equity in HiAP can yield positive results. This article discusses these ideas and presents potential actions to restore HiAP's once central equity objectives, which include: seeking synergies focused on health equity with those who hold different convictions, both in terms of goals and measures of success; considering the conditions that allow HiAP to be fostered, such as good governance; and drawing on research on HiAP and other multisectoral approaches.

A "bottom up" Health in All Policies program: Supporting local government wellbeing approaches.

A wellbeing economy requires multiple inputs to enable the wholistic vision of a sustainable healthy population and planet. A Health in All Policies (HiAP) approach is a useful way to support policy makers and planners to implement the activities required to support a wellbeing economy. Aotearoa New Zealand's Government has explicitly set a path towards a wellbeing economy. Here, we report the utility of a HiAP approach in Greater Christchurch, the largest urban area in the South Island of New Zealand, to achieving the shared societal goals of a sustainable healthy population and environment. We use the World Health Organisation draft Four Pillars for HiAP implementation as a framework for discussion. SO WHAT?: The paper adds to the growing number of examples of city and regions supporting a wellbeing agenda, specifically focused on some of the successes and challenges for local HiAP practitioners working within a public health unit in influencing this work.