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- 1. MODULE 3 Health in All Policies (HiAP) 3 PUBLIC HEALTH, HiAP AND ITS DEVELOPMENT
- 2. LEARNING OBJECTIVES 3 Define public health and HiAP 1 Explain the origins and development of HiAP 2 Recognize when to use a HiAP approach 3 Distinguish the HiAP approach from other public policies 4
- 3. PUBLIC HEALTH DEFINITION 3 Public health refers to all organized efforts to prevent disease, promote health and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Public health is concerned with the total system and not only the eradication of a particular disease.
- 4. PUBLIC HEALTH FUNCTIONS 3 THE THREE MAIN PUBLIC HEALTH FUNCTIONS ARE: Assessment – monitor health; assess the population and investigate Policy development – inform, educate, empower; mobilize partnerships; develop polices Assurance – enforce laws; link to/provide care; assure competent workforce; evaluate.
- 6. 3 HiAP is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity. WHO (2013) Helsinki Statement on Health in All Policies. WHO 8th Global Conference on Health Promotion. DEFINITION OF HEALTH IN ALL POLICIES (HiAP)
- 7. 3 Source: diagram developed by authors from analysis in Leppo K et al. (2013) Health in All Policies: Seizing opportunities, implementing policies. Finland, Ministry of Social Affairs and Health, p. 329. COMPLEX HEALTH CHALLENGES GOVERNMENT PRIORITY AFFECTING MANY SECTORS EXTERNAL POLICIES WITH HIGH IMPACT ON HEALTH POLICY SITUATIONS THAT FAVOUR A HiAP APPROACH
- 8. 3 Problem or issue is of major public health importance; SEVERAL CONSIDERATIONS ARE USEFUL TO HELP PRIORITIZE WHICH ISSUES TO ADDRESS: Problem or issue is amenable to change and change is feasible. There is sound evidence that it can be tackled; and Potential solutions are politically and socially acceptable. PRIORITIZING OF ISSUES FOR HiAP ACTION
- 9. APPROACHES TO PUBLIC HEALTH: ANCIENT TIMES 3 For many centuries, explanations for disease were based not on science, but on religion, superstition, and myth. Around 400 BCE the idea of four bodily humours was established by Hippocrates. Greek medicine was based on these four humours – the imbalance of humours was the direct cause of all disease.
- 10. APPROACHES TO PUBLIC HEALTH: THE 19TH CENTURY 3 The 19th century marked a great advance in public health. The “sanitary-environmental approach” – focused on ensuring people lived and worked in healthy conditions: tied to HiAP. The “biomedical approach” – late 19th century: enter bacteriology. Early 20th century: move toward personal care.
- 11. APPROACHES TO PUBLIC HEALTH: MID- 20TH CENTURY AND BEYOND 3 “Social-behavioural approach”, which focuses on lifestyles and behavioural change drawing on psychological theories to reduce disease risk factors. Health promotion emerges more strongly. Efforts to change behaviour have rarely had sustainable health gains in the absence of more structural changes to the conditions shaping people’s health in their everyday lives.
- 12. RECENT HISTORY OF HiAP AND INTERNATIONAL MILESTONES 3 Alma-Ata Declaration on Primary Health Care (1978) Ottawa Charter for Health Promotion (1986) International Conference on Health Promotion, Adelaide (1988) Adelaide Statement on Health in All Policies (2010) Rio Political Declaration on Social Determinants of Health (2011) UN General Assembly Resolution on the Prevention and Control of Non-Communicable Diseases (2011) Second Adelaide Statement on Health in All Policies (2017 and updated in 2019) HiAP promoted by international organizations, in particular the WHO, and also through the European Union.
- 13. WORLD CONFERENCE ON SOCIAL DETERMINANTS OF HEALTH RIO DE JANEIRO, BRAZIL, 19-21 OCTOBER 2011 3 RIO POLITICAL DECLARATION ON SOCIAL DETERMINANTS OF HEALTH 1 2 3 4 5 To monitor progress and increase accountability To strengthen global governance and collaboration To further reorient the health sector towards reducing health inequities To promote participation in policy-making and implementation To adopt better governance for health and development
- 14. WHY HiAP MATTERS? 3 Many of the determinants of health and health inequities in populations have social, environmental and economic origins that extend beyond the direct influence of the health sector and health policies. Therefore, public policies and decisions made in all sectors and at different levels of governance can have a significant impact on population health and health equity. Health considerations need to be taken into account in policy-making: opportunities for co-benefits.
- 15. MULTI SECTORAL ACTION - WHY IS THIS DIFFICULT? 3 Complex policy issues are often multi-determinate Action by a number of government agencies or institutions - working together is required Communication – issues in finding a common language Siloed thinking, conflicting interests, power imbalances Such factors make joined-up governance difficult
- 16. HiAP FRAMEWORK FOR COUNTRY ACTION 3 ✓ systematically takes into account the health implications of decisions ✓ seeks synergies ✓ avoids harmful health impacts World Health Assembly 68.17 (2015) Putting the action across sectors into practise Facilitate assessment and engagement Establish the need and priorities for action across sectors Identify supportive structures and processes Frame planned actions Establish a monitoring and evaluation mechanism Build capacity
- 17. End of Module 3 Please continue to Module 4 Part 1
Editor's Notes
- Title slide
- Briefly summarize the key objectives for this lecture. This lecture is about formally introducing the concept of HiAP now that all of the participants, even those from a non-health background, have a basic understanding of contemporary health challenges such as NCDs and the importance of the determinants of health. After defining the concepts of public health and HiAP, this lecture looks to put them in their historical context.
- Public health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988). Activities to strengthen public health capacities and service aim to provide conditions under which people can maintain to be healthy, improve their health and well-being, or prevent the deterioration of their health. Public health focuses on the entire spectrum of health and well-being, not only the eradication of particular diseases. Overall, public health is concerned with protecting the health of entire populations. These populations can be small as a local neighbourhood, or as big as an entire country or region of the world. Approaches to public health have varied over time in the way health problems have been viewed and solved. The understanding that health is influenced by many factors (i.e. determinants) such as food, housing and working conditions outside the health sector has a long history of at least several centuries. This approach to public health has prevailed in many regions of the world.
- The three main public health functions are: Assessment - The assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities. Policy development – The formulation of public policies designed to solve identified local and national health problems and priorities. Public health promotes the use of a scientific knowledge base in policy and decision-making. Assurance – To assure that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services.
- Public health professionals monitor and diagnose the health concerns of entire communities and promote healthy practices and behaviours to ensure that populations stay healthy. Because social, environmental, and biologic factors interact to determine health, public health practice must utilize a broad set of skills and interventions. This slide shows the breadth of public health. One way to illustrate the breadth of public health is to look at some notable public health campaigns: Vaccination and control of infectious diseases; Motor vehicle safety; Safer workplaces; Safer and healthier foods; Safe drinking water; Healthier mothers and babies and access to family planning; Decline in deaths from coronary heart disease and stroke; and Recognition of tobacco use as a health hazard.
- HiAP is one approach to public health. The term HiAP emerged during the past two decades, however, working across sectors to achieve good public health outcomes is not a new concept. HiAP belongs to a tradition of public health approaches that focus on the social and political factors that strongly influence population health. It is built on the foundations of public health from the 19th and 20th century, and has emerged as the next iteration of conceptual thinking and strategic practice to bring about improved population health. Historically, efforts to address the social, economic, environmental and commercial determinants of health have required collaboration across multiple sectors and often necessitated political and social struggle. HiAP is being acknowledged internationally as one of the effective ways of implementing intersectoral action on the social determinants of health and health inequities, and aims to strengthen the political will for action by providing a systematic approach for addressing the determinants of health, and moving action beyond the health sector and into the policy domains of sectors outside of health. HiAP is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity. It improves the accountability of policy-makers for health impacts at all levels of policy-making. It includes an emphasis on the consequences of public policies on health systems, determinants of health and well-being. HiAP has been implemented differently in different contexts reflecting local social and political cultures as well as government structures. It is important to share experiences and lessons learnt to understand how HiAP can be most effective. In a later lecture, some examples of how HiAP is being implemented in different regions will be presented (see Module 9).
- There are three general policy situations that favour a HiAP approach. 1. Complex health challenges. This is the most common policy situation where a HiAP approach should be considered and refers to population health, health equity or health systems challenges that require intersectoral policy solutions. It is important to have strong evidence of the problem, its causes, potential solutions involving other sectors, especially their technical feasibility, and lastly the potential costs and benefits of action from the perspective of health and society as a whole. Examples of this first scenario might include responding to NCDs, antimicrobial resistance or health risks associated with climate change. 2. External policies with high impact on health. This is another policy situation that favours a HiAP approach and concerns policy proposals originating from sectors outside of health that could have a significant impact on health or health equity. Numerous government policies can impact on health yet the health sector has to prioritize when to engage heavily with other sectors since this requires significant resources and time. A HiAP approach can help focus and legitimize the health sector’s engagement in policy decisions that have significant (indirect) impacts on health. This policy situation can equally apply to international declarations or agreements. Examples of this second scenario might include: free trade agreements and environmental protection laws. 3. Government priority affecting many sectors. This policy situation can arise when the government has a high priority goal that both requires intersectoral collaboration and affects the health sector. In this situation, the health sector has a valuable opportunity to promote and facilitate intersectoral action to achieve an important government objective at the same time as advancing health’s own agenda. This proactive engagement can strengthen ties with other sectors and establish a reputation of expertise and reliability, which can be called upon when needed later. Examples of this third scenario might include: improving early childhood development or responding to food insecurity.
- Within these three policy situations, it is still necessary to prioritize which issues to address. There are no permanent and certain rules but several considerations are useful. Potential issues for action should be chosen by applying criteria such as: Problem or issue is of major public health importance; Problem or issue is amenable to change and change is feasible. That is, there is sound evidence that it can be tackled; and Potential solutions are politically and socially acceptable.
- Now that we have defined the concepts of public health and HiAP, we will look more closely at their historical context to understand how and why HiAP has emerged out of the public health and health promotion fields. Early explanations for the occurrence of disease focused on superstition, myths, and religion. In ancient times, many cultures believed that disease was caused by an imbalance in the body or by evil or sin. In ancient Greece, physicians believed health to be an internal equilibrium of the four bodily humours: blood, phlegm, black bile and yellow bile. Health depended on a proper balance of these humours. While crude, this concept of humours provided some sort of rationale for understanding health and disease. And in ancient China, as in ancient Greece, the first physicians based their treatment on correcting imbalances of the five phases or elements: wood, fire, earth, metal and water. In ancient Egypt, evil gods and demons were thought to be responsible for many ailments, and often the treatments involved a supernatural element, such as beginning the treatment with an appeal to a deity. As such, there was no clear distinction between the functions of a priest and a physician.
- The 19th century marked a great advance in public health and is sometimes referred to as the “the great sanitary awakening” – the identification of ‘filth’ as both a cause of disease and a vehicle of transmission and the embrace of cleanliness – was a central component of 19th century social reforms. Sanitation changed the way society thought about health. Illness came to be seen as an indicator of poor social and environmental conditions, as well as poor moral and spiritual conditions. With sanitation, public health became a societal goal and protecting health became a public activity. Due to the deplorable social and environmental conditions and the constant threat of disease spread, diseases came to be considered an indicator of a societal problem as well as a personal problem. It became apparent that poverty and disease could no longer be treated simply as individual failings and that the spread of contagious disease in growing cities was not selective (i.e. the plague had been regarded as a disease of the poor; in an urbanized 19th century, it became obvious that the wealthy could not escape contact with the poor). HiAP has ties to this “sanitary-environmental approach” to public health. This is also sometimes referred to as the salutogenic model. This approach focuses on ensuring people live and work in healthy conditions. This means, for example, having adequate housing, proper sanitation, access to uncontaminated food and clean water, and a safe work environment. Importantly, it has been shown that improvements in living conditions and better nutrition were primarily responsible for the dramatic reductions in mortality in European industrialized countries in the 1800s. This is because mortality rates fell and life expectancies rose prior to the introduction of most effective medical interventions. The same approach to public health focusing on healthy living conditions and basic needs can also be credited with increasing life expectancies in many developing countries. In the 1930s, many Latin American countries initiated major public interventions within and outside the health sector such as improving access to water, food and nutrition, sanitation, housing, education and transport. Other countries that made similar transitions during the mid-20th century include China, India and Indonesia. Another major set of developments in public health took place at the close of the 19th century. Rapid advances in scientific knowledge about causes and prevention of numerous diseases brought about tremendous changes in public health. Many major contagious diseases were brought under control through science applied to public health. The identification of bacteria and the development of interventions such as immunization and water purification techniques provided a means of controlling the spread of disease and even of preventing disease. During this period public agencies that had been developed to conduct and enforce sanitary measures refined their activities and expanded into laboratory science and epidemiology. Public responsibility for health came to include both environmental sanitation and individual health. This gave rise to what certain scholars refer to as a “biomedical approach” to public health focusing on the control and treatment of disease, especially those of a communicable nature. Since this time, the biomedical approach has been prominent and is typified by mass vaccination campaigns and the development of new drugs to treat disease. In the early 20th century it became clear that providing immunizations and treating infectious diseases did not solve all health problems. Despite remarkable success in lowering death rates from typhoid, diphtheria, and other contagious diseases, considerable disability continued to exist in the population. There were still numerous diseases, such as tuberculosis, for which infectious agents were not clearly identified. Draft registration during World War I revealed that a substantial portion of the male population was either physically or mentally unfit for combat. It also became clear that diseases, even those for which treatment was available, still predominately affected the urban poor and children. On the premise that a healthier society could be built through health care for individuals, health departments expanded into clinical care and health education, and the orientation of public health shifted from disease prevention to promotion of overall health. Promoting programs for individual health and campaigns against specific health problems grew.
- During the 20th century, the historic emphasis on protecting communities from infectious disease and environmental threats expanded to counter risks from behaviours and lifestyles that led to chronic disease. In the 20th century, promoting a healthy society was achieved through scientific analysis of disease, medical treatment of individuals, and education on healthy habits. In 1923, C.E.A. Winslow (an American bacteriologist and public health expert) defined public health as the science of not only preventing contagious disease, but also of “prolonging life, and promoting physical health and efficiency”.1 Another trend in public health emerged – the “social-behavioural approach” – which focuses on lifestyles and behavioural change drawing on psychological theories to reduce disease risk factors. Examples of this approach might include campaigns against risky behaviours such as problem drinking, substance abuse, reckless driving and unprotected sexual intercourse. Such efforts to change behaviour have sometimes had success but rarely in the absence of more structural changes to the conditions shaping people’s health in their everyday lives. In addition, by the late 20th century, in industrialized countries, containing health costs became a major objective of governments. Per capita health expenditures were increasing. The financing of medical care was in crisis and new approaches to population health were deemed necessary, especially in the wake of new emerging public health challenges such as obesity and impacts of climate change on human health. 1 Winslow, as quoted in Hanlon and Pickett, 1984. Hanlon, G. & Pickett J. 1984. Public Health Administration and Practice. Times Mirror/Mosby.
- The critical practices within public health and health promotion fields have provided the foundations of Health in All Policies. There have also been critical movements that have shaped the development of Health in All Policies, including the importance of World Health Organization statements and the World Conference on the Social Determinants of Health in Rio de Janeiro, Brazil in October 2011. The concepts behind Health in All Policies have their origin in the Declaration of Alma-Ata, where the importance of intersectoral action for health was first acknowledged. It recognised that health and well-being is influenced by the decisions and policies of outside of health sectors, and that to achieve significant health gains the health sector would need to work in partnership across sectors. The Ottawa Charter for Health Promotion, which resulted from the First International Conference on Health Promotion, launched a series of actions to achieve the goal of ‘Health for All’ by the year 2000 and beyond through better health promotion. The World Health Organization convened a second International Conference on Health Promotion in Adelaide in 1988, which focused on building healthy public policy. Subsequent health promotion conferences focused on achieving health and health equity through creating a health-conducive environment, building effective partnerships, addressing social determinants and taking country action. In 2010, the Government of South Australia and the World Health Organization co-hosted the International Meeting on Health in All Policies in Adelaide, which produced the Adelaide Statement on Health in All Policies. The first Adelaide Statement outlines the need for a new social contract between all sectors to advance human development, sustainability and equity, as well as to improve health outcomes. Importantly, this statement highlighted that this requires a new form of governance where there is joined-up leadership within governments, across all sectors and between levels of government. The HiAP approach has been reinforced in the more recent 2011 Rio Political Declaration on Social Determinants of Health and the UN General Assembly Resolution on the Prevention and Control of Non-Communicable Diseases. A Second Adelaide Statement on Health in All Policies was developed in 2017, an outcome of the International Conference on Health in All Policies in Adelaide, and for the first time formally linked Health in All Policies to the 2030 Sustainable Development Agenda, outlining Health in All Policies as a robust strategy for supporting the achievement of the 17 Sustainable Development Goals (the second Adelaide statement was updated in 2019). During recent times, HiAP has been promoted systematically by international organizations, in particular the WHO, but also through the European Union. The increasing push towards more effective forms of governance and the recognition of the systemic nature of public policy in general has also led to a growing interest in HiAP as an innovative way to address health challenges through collaboration.
- The Rio Political Declaration on Social Determinants of Health was adopted during the World Conference on Social Determinants of Health on 21 October 2011 and endorsed five priority areas. The declaration expresses global political commitment for the implementation of a social determinants of health approach to reduce health inequities and to achieve other global priorities. It aimed to help build momentum within countries for the development of dedicated national action plans and strategies that addressed the social determinants of health, including Health in All Policies.
- Health and health equity are values in their own right, and are also important prerequisites for achieving many other societal goals. Many of the determinants of health and health inequities in populations have social, environmental and economic origins that extend beyond the direct influence of the health sector and health policies. Thus, public policies and decisions made in all sectors and at different levels of governance can have a significant impact on population health and health equity. The HiAP approach is, therefore, necessary to protect and promote health and health equity, particularly where there are competing interests. It ensures that health and health equity considerations become part of decision-making. HiAP recognizes that governments are faced with a range of priorities and that health and equity may not automatically gain precedence over other policy objectives. Nonetheless, health considerations do need to be taken into account in policy-making. Efforts must be made to capitalize on opportunities for co-benefits across sectors and for society at large.
- In a simple policy environment, relevant sectors may have shared visions where their sectoral goals are mutually gained. For example, in confronting zoonotic diseases which threaten human security. In more complex policy environments, responsibilities are shared across sectors with unclear boundaries, or where there might be conflicting sectoral goals and institutional mandates. Here, implementing multisectoral action is the most challenging.
- The HiAP Framework for Country Action provides countries with a practical means of enhancing a coherent approach to HiAP. The framework sets out six key components to facilitate action on health and health equity: Establish the need and priorities for action across sectors Frame planned actions Identify supportive structures and processes Facilitate assessment and engagement Ensure monitoring, evaluation and reporting Build capacity These six components are not fixed in order or priority. Rather, they can be adopted and adjusted in ways that are most relevant for specific governance, economic and social contexts.