Health in All Policies (HiAP) is a strategy that seeks to integrate health considerations into the development, implementation and evaluation of policies across various non-health sectors of the government. Over the past 15 years, there has been an increase in the uptake of HiAP by local, regional and national governments. Despite the growing popularity of this approach, most existing literature on HiAP implementation remains descriptive rather than explanatory in its orientation. Moreover, prior research has focused on the more technical aspects of the implementation process. Thus, studies that aim to ‘build capacity to promote, implement and evaluate HiAP’ abound. Conversely, there is little emphasis on the political aspects of HiAP implementation. Neglecting the role of politics in shaping the use of HiAP is problematic, since health and the strategies by which it is promoted are partially political.
This glossary addresses the politics gap in the existing literature by drawing on theoretical concepts from political, policy, and public health sciences to articulate a framework for studying how political mechanisms influence HiAP implementation. To this end, the glossary forms part of an on-going multiple explanatory case study of HiAP implementation, HARMONICS (HiAP Analysis using Realist Methods on International Case Studies, harmonics-hiap.ca), and is meant to expand on a previously published glossary addressing the topic of HiAP implementation more broadly. Collectively, these glossaries offer a conceptual toolkit for understanding how politics explains implementation outcomes of HiAP.
- Health inequalities
- HEALTH POLICY
- PUBLIC HEALTH POLICY
- HEALTH PROMOTION
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Health in All Policies (HiAP) is a governance approach that seeks to integrate health considerations into the development, implementation and evaluation of policies across various sectors of government. Over the past 15 years, various policies and long-term strategies that resemble HiAP have been adopted by local, regional and national governments.1 2 These examples of HiAP range from downstream interventions that aim to change individual behaviours (eg, raising taxes on tobacco and alcohol to reduce their consumption) to upstream interventions that aim to modify social and economic environments (eg, the enactment of living wage legislation to reduce poverty rates).
Despite the growing popularity of HiAP, most existing literature on its implementation remains descriptive rather than explanatory in its orientation.2 Moreover, prior research has focused on the more technical aspects of the implementation process. For example, a large body of work describes the different methods available for undertaking health impact assessments and highlights the need to enhance the capacity of civil servants to conduct such evaluations. Indeed, studies that aim to ‘build capacity to promote, implement and evaluate HiAP’ abound (p4).3 Conversely, there is little emphasis on the political aspects of HiAP implementation. Neglecting the role of politics in shaping the use of HiAP is problematic, since health and the strategies by which it is promoted are partially political.4 5
Given the paucity of political thinking within the public health literature,6–10 it does not come as a surprise that theoretical contributions from the political sciences have made few inroads into the HiAP literature. Rarely, for example, do public health researchers use theories developed by political scientists, despite the relevance of these theories to the analysis of public health policy.8 11 More generally, the prevailing conceptualisation of policymaking as merely a form of legislative or regulatory action is at odds with the core theoretical constructs informing contemporary political research.11 12
In light of the above considerations, this glossary addresses the politics gap in the existing literature by building on the previous politics of health glossary by Bambra et al,13 which used key concepts from the political science literature to raise awareness within public health of the political aspects of health and health inequities. We also build on the work by Freiler and colleagues,14 who examined the techniques, structures and strategies operating in HiAP. We extend these glossaries by drawing on theoretical concepts from political, policy and public health sciences to articulate a framework for studying how political mechanisms influence HiAP implementation. The definitions presented here are normative and thus contestable; we do not seek to present any non-political definitions nor to present every possible definition of these terms. These definitions emerged from an ongoing multiple explanatory case study of HiAP implementation. Collectively, these glossaries offer a conceptual toolkit for understanding how politics helps to explain the implementation outcomes of HiAP.
Politics in the implementation of HiAP
Political agenda refers to the finite set of cultural, economic and political issues that are the focus of debate and decision making within a political system.15 Policymakers are routinely confronted with a multitude of problems; the political agenda explains the subset of issues and policies upon which a government acts on at a given point in time.
In order for HiAP implementation to be successful, it must appear and remain on the political agenda. Whether or not HiAP earns a place on the political agenda depends on a confluence of factors. For example, the political agenda is set by the executive branch of the government and therefore tends to reflect the ideology of that executive. It is also shaped by policy elites external to the government who can act or advise the government to bring new issues onto the political agenda. Finally, a range of other issues and policies may indirectly affect how HiAP is understood by policymakers. For example, the perception of economic crisis by political elites can affect the political agenda by shifting policymakers’ attention away from new spending towards opportunities for cost savings.16 Thus, if HiAP can be viewed as an opportunity for some long-term cost savings, it may be more likely to appear on the political agenda during times of economic crisis. In South Australia, the focus on prevention through a HiAP strategy was, in part, a response to the rising costs of healthcare system.17
In relation to the policy implementation process, political elites are people holding ‘authoritative positions’ (p474) who,18 by virtue of their privileged positions within government, tend to have regular and greater influence than policy elites.19 The influence of political elites can be related to their legal role within governments, which grants them certain formal authority. For instance, formal authority of political elites may give them access to veto powers that can be used to direct political outcomes.20 As one example, in presidential—as opposed to parliamentary—systems of government, the head of state is sovereign and therefore determines policy independently of other elected officials; that is, they have strong veto power. Rather, the consent of members of their cabinet may be relatively more influential.19 21 22
Political elites have influence over the design, implementation, orientation and evaluation of HiAP. For example, whether or not governments are successful in implementing HiAP may depend on the density of veto powers, their availability to various political elites who may influence them, and the ideologies and political agendas of these political elites. Political elites may also influence the agenda setting process when policy sectors negotiate over policy coordination, either by encouraging a focus on particular policy objectives or by lending their power to help resolve disputes. For example, in Sweden the influence of political elites shifted the focus of HiAP from structural (upstream) to behavioural (downstream) interventions.
Policy elites are actors who work within or have significant knowledge of a specific area of policy, and thus have significant influence over the policymaking process.21 Policy elites can be internal or external to the government. For instance, civil servants have the opportunity to draw on their substantive expertise and experience to advise or influence the government executives who oversee their sectors.22 Outside of the government, expert advisors (eg, scientists, private sector consultants, former government officials) can be brought in to help plan, manage and evaluate HiAP implementation. Non-governmental policy elites can also include representatives of community advocacy groups, social movements and private or professional interest groups that may provide solicited or unsolicited advice.3 For example, in South Australia, an academic expert was formally engaged through the government’s Thinker-in-Residence programme to spearhead the development and implementation of an HiAP initiative.
Ideological biases of policy elites can undermine the political neutrality necessary for technical aspects of policymaking.22 Policy elites hold certain values and beliefs that can shape the nature of their participation in HiAP implementation. Policy elites can exercise their power through administrative, professional and lobbying processes during the implementation of HiAP in an effort to secure a specific set of political outcomes. Governments, in turn, can be more or less receptive to the influence of different policy elites. For example, the alcohol lobby in Finland successfully influenced the government to lower alcohol taxes, even after a health impact assessment recommended raising taxes to protect public health.23 Whether or not a given set of policy elites has privileged access to the policymaking process and the relative magnitude of power they are able to exercise over that process also depends on the institutional context and broader political culture in which they are operating.
Power can be understood as the ability to influence the behaviour of others to impact decisions and achieve desired outcomes.13 Power is also exercised in interactions that limit or shape the scope of the political process (see Political agenda).24 Institutional power is power exerted by governmental and non-governmental actors within institutions (eg, labour market, education). Asymmetry of power (eg, as indicated by power resources)25 26 can help elucidate how certain groups within government control issues of interest. Leadership is another area of interest in the study of policy implementation where actors within institutions get desired results by using their power. Elementary forms of power that can explain how desired influence is achieved include corrective influence using punishments and rewards, and persuasive forms of inducement where some external motivator is used to indirectly influence behaviour.25 For example, actors may seek to change governance structures and use expertise to create and legitimise shared meanings and values to produce specific results.
In the context of HiAP implementation, institutional power is usually understood as involving social relationships within government but can also involve relationships with non-governmental actors (see Policy elites). Since health inequities are maintained and reproduced over time through power within governmental institutions,27 this conceptualisation of power allows for an examination of how power is exercised to explain why a specific health equity or HiAP result was (or was not) achieved.
For example, since HiAP is coordinated primarily by government institutions,14 conflicting political interests or goals (eg, austerity and short-term gains vs investment in social infrastructure with longer periods of effect) may result in power struggles between different government sectors. This may affect funding for HiAP activities and result in material constraints for HiAP implementation. These conflicting interests may be mitigated in a variety of ways, for example, through the influence of a strong HiAP mandate, or strong leadership by government executives (see Political elites) or activism of civil servants. In Sweden, as partnerships were developed to address the Swedish Public Health Objectives Bill, a scientific report describing multisectoral determinants of public health and sustainable development helped draw partners from across the ideological spectrum by avoiding political statements and focusing on translating concrete facts.28 29
Ideology refers to the set of ideas, including values and beliefs, according to which people generate normative and causal arguments about the role of states, markets and individuals in fostering well-being, including health equity.30 The dominance of a particular ideology reflects the power and the values of the group it represents, which has implications for population health.13 Influential political actors, such as heads of state (see Political elites), often rely on ideological constructs to generate blueprints for policy action,31 which end up shaping the issues that a government addresses (see Political agenda) and the means by which they are addressed.
The ideological orientations of political parties ruling the government can have a significant effect on the nature of the political agenda as a whole that affects HiAP implementation. For example, in the wake of the recent global economic crisis, ideological commitments to austerity became more prominent.32 33 An ideological commitment to austerity implies that the perceived fiscal stability of the state should be restored through an overall reduction in public spending to re-establish growth.34 This agenda has been shown to weaken the implementation of HiAP by subordinating social objectives, including health equity, to economic imperatives, as was the case in Finland (see Policy elites).35
These ideological orientations also have an impact on HiAP implementation by influencing the entry points of action on health inequities.1 For instance, in working to reduce inequities between higher and lower income populations, ideological orientation may affect whether government focuses on downstream behavioural determinants of health (eg, smoking) or their upstream structural counterparts (eg, income inequality).27
When engaging in agenda settings for intersectoral action, ideological conflict can arise between sectors that have contrasting sets of values and beliefs. When a sector’s ideological orientation is incompatible with the established HiAP implementation agenda, there may be less buy-in from some partners, or implementation might drift towards behaviour change interventions rather than more upstream action (ie, weaker action on health equity).36
Jurisdiction refers to how authority over and political responsibility for policy issues is distributed across formally constituted bodies in government.37 Jurisdiction can apply across levels of government (eg, federal vs provincial) or within a single level of government (eg, between federal ministries). Jurisdictional overlap occurs when two or more levels or sectors of government believe they have authority over or are responsible for the same policy area; this can lead to jurisdictional conflict between policy actors.
HiAP can represent a threat to traditional jurisdictional control of policy sectors because the process usually involves transforming governments from models that distinguish mandates and budgets of policy sectors (‘policy silos’) towards more integrated forms of governance.38 39 More specifically, conflict can arise when non-health sectors perceive the health sector to be interfering with their jurisdictions and, by extension, undermining their sectoral objectives, what has been referred to as ‘health imperialism’.40 In Ecuador, a new ministry, Secretaría Nacional de Planificación y Desarrollo (SENPLADES-) created to coordinate HiAP activities led to jurisdictional conflict with other sectors. These sectors did not want to give up control over policy issues they previously controlled.
Resource allocation refers to how resources are distributed among competing demands. Welfare economists posit that resources will always be insufficient relative to wants (ie, scarcity), which requires choosing between alternatives and necessitates consideration of opportunity costs. Opportunity cost refers to the cost of the next best alternative that is foregone as a result of the decision.41 Methods to allocate resources range from decisions by political elites without clear principles to algorithms driven by formal economic evaluations, typically on the basis of allocative efficiency (ie, distribution of resources that maximises aggregate welfare), and combinations of approaches including deliberation by non-partisan policy elites. Resource allocation decisions often involve difficult trade-offs between costs, benefits, harms and social values (eg, equity).42 For this reason, the ideological values and beliefs of the political elite can influence the resource allocation process.
In the context of HiAP implementation, there are human, informational, financial and infrastructural resources that can increase feasibility.14 For example, a government may create a new organisation to promote the uptake of HiAP in different sectors, as seen in the case of South Australia’s HiAP unit created specifically for the monitoring and implementation of HiAP.
Importantly, decisions about whether or not to allocate resources for HiAP are usually decided by political elites. For example, in the context of an ideological commitment to austerity, the ruling government is likely to prioritise fiscal stability and deficit reduction over other political objectives, including health equity, and thereby undermine the implementation of HiAP.
Political culture is a set of guiding principles about the proper functioning and role of politics.43 There are five major components of political culture: (1) beliefs about authority; (2) beliefs about group welfare versus individual interests; (3) trade-offs between liberty versus security; (4) the legitimacy of a political system and its leaders; and (5) the political community.43 Political culture is a product of the histories of political systems and individual members of those systems; consequently, it is rooted both in public events and private experiences.43 Others have noted how globalisation can have a socialising effect on the various political cultures that become interconnected.16 When members of a political system share the same attitudes, norms, beliefs or values, the political system is characterised by a given political culture (eg, liberal, authoritarian, corrupt, bureaucratic).44
A political culture that values group welfare (collectivist political culture) over individual interests (individualistic political culture, for discussion see ref 16) is more likely to adopt HiAP policies that address the social determinants of health. Similarly, the design and focus of HiAP interventions are often aligned with the political culture of a jurisdiction. In Thailand, for example, HiAP implementation is driven by political culture in Thailand that values community interests and community involvement in decision making.45
Political support refers to citizens’ acceptance or rejection of particular governments.46 Political support for government is expected to be high when political rights are extensive, such as in parliamentary executives, multiparty systems, federal states and proportional electoral systems.47 Political support lends legitimacy to a government.48 Legitimacy, in turn, is largely influenced by the perceived performance of a government.49 In this sense, political systems that are ineffective in meeting public expectations over a period of time can lose their legitimacy.
Political support is an important determinant of HiAP implementation because it can influence the length of HiAP and the type of HiAP (eg, upstream, midstream or downstream) that a government implements. For example, the Thai government originally implemented HiAP as a response to popular dissent following an economic crisis in 1997 which led to strong support for social structuring. Thus the implementation of HiAP in Thailand focuses on addressing the social determinants of health (rather than merely addressing lifestyles and other behaviours), with citizens being empowered to demand a health impact assessment about developments that are perceived to be harmful.50
The authors would like to gratefully acknowledge the advice of Dr Joseph Wong and support of Sundus Haji-Jama.
Contributors GO, FVS, CM, AMB, DFM, AF, PO and KS contributed equally to the conceptualisation, writing and editing of this manuscript.
Funding This work was supported by Canadian Institute of Health Research grant numbers 111608 and 96566. AMB supported by a Canadian Institutes of Health Research/Ontario Ministry of Health and Long-Term Care Applied Chair in Health Services and Policy Research and is currently supported by the Fondation Baxter & Alma Ricard Chair in Inner City Health at St Michaelâ€™s Hospital and the University of Toronto.
Competing interests None declared.
Patient consent Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
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