The future of public health policymaking after COVID-19: lessons from Health in All Policies

Behold Paul’s attempt to make our faces the same size

Paul Cairney, Emily St Denny, Heather Mitchell 

This post summarises new research on the health equity strategy Health in All Policies. As our previous post suggests, it is common to hope that a major event will create a ‘window of opportunity’ for such strategies to flourish, but the current COVID-19 experience suggests otherwise. If so, what do HIAP studies tell us about how to respond, and do they offer any hope for future strategies? The full report is on Open Research Europe, accompanied by a brief interview on its contribution to the Horizon 2020 project – IMAJINE – on spatial justice.

COVID-19 should have prompted governments to treat health improvement as fundamental to public policy

Many had made strong rhetorical commitments to public health strategies focused on preventing a pandemic of non-communicable diseases (NCDs). To do so, they would address the ‘social determinants’ of health and health inequalities, defined by the WHO as ‘the unfair and avoidable differences in health status’ that are ‘shaped by the distribution of money, power and resources’ and ‘the conditions in which people are born, grow, live, work and age’.

COVID-19 reinforces the impact of the social determinants of health. Health inequalities result from factors such as income and social and environmental conditions, which influence people’s ability to protect and improve their health. COVID-19 had a visibly disproportionate impact on people with (a) underlying health conditions associated with NCDs, and (b) less ability to live and work safely.

Yet, the opposite happened. The COVID-19 response side-lined health improvement

Health departments postponed health improvement strategies and moved resources to health protection.

This experience shows that the evidence does not speak for itself

The evidence on social determinants is clear to public health specialists, but the idea of social determinants is less well known or convincing to policymakers.

It also challenges the idea that the logic of health improvement is irresistible

Health in All Policies (HIAP) is the main vehicle for health improvement policymaking, underpinned by: a commitment to health equity by addressing the social determinants of health; the recognition that the most useful health policies are not controlled by health departments; the need for collaboration across (and outside) government; and, the search for high level political commitment to health improvement.

Its logic is undeniable to HIAP advocates, but not policymakers. A government’s public commitment to HIAP does not lead inevitably to the roll-out of a fully-formed HIAP model. There is a major gap between the idea of HIAP and its implementation. It is difficult to generate HIAP momentum, and it can be lost at any time.

Instead, we need to generate more realistic lessons from health improvement and promotion policy

However, most HIAP research does not provide these lessons. Most HIAP research combines:

1. functional logic (here is what we need)
2. programme logic (here is what we think we need to do to achieve it), and
3. hope.

Policy theory-informed empirical studies of policymaking could help produce a more realistic agenda, but very few HIAP studies seem to exploit their insights.

To that end, this review identifies lessons from studies of HIAP and policymaking

It summarises a systematic qualitative review of HIAP research. It includes 113 articles (2011-2020) that refer to policymaking theories or concepts while discussing HIAP.

We produced these conclusions from pre-COVID-19 studies of HIAP and policymaking, but our new policymaking context – and its ironic impact on HIAP – is impossible to ignore.

It suggests that HIAP advocates produced a 7-point playbook for the wrong game

The seven most common pieces of advice add up to a plausible but incomplete strategy:

1. adopt a HIAP model and toolkit
2. raise HIAP awareness and support in government
3. seek win-win solutions with partners
4. avoid the perception of ‘health imperialism’ when fostering intersectoral action
5. find HIAP policy champions and entrepreneurs
6. use HIAP to support the use of health impact assessments (HIAs)
7. challenge the traditional cost-benefit analysis approach to valuing HIAP.

Yet, two emerging pieces of advice highlight the limits to the current playbook and the search for its replacement:

1. treat HIAP as a continuous commitment to collaboration and health equity, not a uniform model; and,
2. address the contradictions between HIAP aims.

As a result, most country studies report a major, unexpected, and disappointing gap between HIAP commitment and actual outcomes

These general findings are apparent in almost all relevant studies. They stand out in the ‘best case’ examples where: (a) there is high political commitment and strategic action (such as South Australia), or (b) political and economic conditions are conducive to HIAP (such as Nordic countries).

These studies show that the HIAP playbook has unanticipated results, such as when the win-win strategy leads to  HIAP advocates giving ground but receiving little in return.

HIAP strategies to challenge the status quo are also overshadowed by more important factors, including (a) a far higher commitment to existing healthcare policies and the core business of government, and (b) state retrenchment. Additional studies of decentralised HIAP models find major gaps between (a) national strategic commitment (backed by national legislation) and (b) municipal government progress.

Some studies acknowledge the need to use policymaking research to produce new ways to encourage and evaluate HIAP success

Studies of South Australia situate HIAP in a complex policymaking system in which the link between policy activity and outcomes is not linear.  

Studies of Nordic HIAP show that a commitment to municipal responsibility and stakeholder collaboration rules out the adoption of a national uniform HIAP model.

However, most studies do not use policymaking research effectively or appropriately

Almost all HIAP studies only scratch the surface of policymaking research (while some try to synthesise its insights, but at the cost of clarity).

Most HIAP studies use policy theories to:

1. produce practical advice (such as to learn from ‘policy entrepreneurs’), or
2. supplement their programme logic (to describe what they think causes policy change and better health outcomes).

Most policy theories were not designed for this purpose.

Policymaking research helps primarily to explain the HIAP ‘implementation gap’

Its main lesson is that policy outcomes are beyond the control of policymakers and HIAP advocates. This explanation does not show how to close implementation gaps.

Its practical lessons come from critical reflection on dilemmas and politics, not the reinvention of a playbook

It prompts advocates to:

• Treat HIAP as a political project, not a technical exercise or puzzle to be solved.
• Re-examine the likely impact of a focus on intersectoral action and collaboration, to recognise the impact of imbalances of power and the logic of policy specialisation.
• Revisit the meaning-in-practice of the vague aims that they take for granted without explaining, such as co-production, policy learning, and organisational learning.
• Engage with key trade-offs, such as between a desire for uniform outcomes (to produce health equity) but acceptance of major variations in HIAP policy and policymaking.
• Avoid reinventing phrases or strategies when facing obstacles to health improvement.

We describe these points in more detail here:

Our Open Research Europe article (peer reviewed) The future of public health policymaking… (europa.eu)

Paul summarises the key points as part of a HIAP panel: Health in All Policies in times of COVID-19

ORE blog on the wider context of this work: forthcoming

Coronavirus and the ‘social determinants’ of health inequalities: lessons from ‘Health in All Policies’ initiatives

Many public health bodies are responding to crisis by shifting their attention and resources from (1) a long-term strategic focus on reducing non-communicable diseases (such as heart diseases, cancers, diabetes), to (2) the coronavirus pandemic.

Of course, these two activities are not mutually exclusive, and smoking provides the most high-profile example of short-term and long-term warnings coming together (see Public Health England’s statement that ‘Emerging evidence from China shows smokers with COVID-19 are 14 times more likely to develop severe respiratory disease’).

There are equally important lessons – such as on health equity – from the experiences of longer-term and lower-profile ‘preventive’ public health agendas such as ‘Health in All Policies’ (HIAP).*

What is ‘Health in All Policies’?

HIAP is a broad (and often imprecise) term to describe:

1. The policy problem. Address the ‘social determinants’ of health, defined by the WHO as ‘the unfair and avoidable differences in health status … shaped by the distribution of money, power and resources [and] the conditions in which people are born, grow, live, work and age’.
2. The policy solutions. Identify a range of policy instruments, including redistributive measures to reduce economic inequalities, distributive measures to improve public services and the physical environment (including housing), regulations on commercial and individual behaviour, and health promotion via education and learning.
3. The policy style. An approach to policymaking that encourages meaningful collaboration across multiple levels and types of government, and between governmental and non-governmental actors (partly because most policy solutions to improve health are not in the gift of health departments).
4. Political commitment and will. High level political support is crucial to the production of a holistic strategy document, and to dedicate resources to its delivery, partly via specialist organisations and the means to monitor and evaluate progress.

As two distinctive ‘Marmot reviews’ demonstrate, this problem (and potential solutions) can be described differently in relation to:

• Global health inequalities

• Health inequalities within a particular area such as England

Either way, each of the 4 HIAP elements highlights issues that intersect with the impact of the coronavirus: COVID-19 has a profoundly unequal impact on populations; there will be a complex mix of policy instruments to address it, and many responses will not be by health departments; an effective response requires intersectoral government action and high stakeholder and citizen ownership; and, we should not expect current high levels of public, media, and policymaker attention and commitment to continue indefinitely or help foster health equity (indeed, even well-meaning policy responses may exacerbate health inequalities). 

A commitment to health equity, or the reduction of health inequalities

At the heart of HIAP is a commitment to health equity and to reduce health inequalities. In that context, the coronavirus provides a stark example of the impact of health inequalities, since (a) people with underlying health conditions are the most vulnerable to major illness and death, and (b) the spread of underlying health conditions is unequal in relation to factors such as income and race or ethnicity. Further, there are major inequalities in relation to exposure to physical and economic risks.

A focus on the social determinants of health inequalities

A ‘social determinants’ focus helps us to place individual behaviour in a wider systemic context. It is tempting to relate health inequalities primarily to ‘lifestyles’ and individual choices, in relation to healthy eating, exercise, and the avoidance of smoking and alcohol. However, the most profound impacts on population health can come from (a) environments largely outside of an individual’s control (e.g. in relation to threats from others, such as pollution or violence), (b) levels of education and employment, and (c) economic inequality, influencing access to warm and safe housing, high quality water and nutrition, choices on transport, and access to safe and healthy environments.

In that context, the coronavirus provides stark examples of major inequalities in relation to self-isolation and social distancing: some people have access to food, private spaces to self-isolate, and open places to exercise away from others; many people have insufficient access to food, no private space, and few places to go outside (also note the disparity in resources between countries).

The pursuit of intersectoral action

A key aspect of HIAP is to identify the ways in which non-health sectors contribute to health. Classic examples include a focus on the sectors that influence early access to high quality education, improving housing and local environments, reducing vulnerability to crime, and reforming the built environment to foster sustainable public transport and access to healthy air, water, and food.

The response to the coronavirus also appears to be a good advert for the potential for intersectoral governmental action, demonstrating that measures with profound impacts on health and wellbeing are made in non-health sectors, including: treasury departments subsidising business and wages, and funding additional healthcare; transport departments regulating international and domestic travel; social care departments responsible for looking after vulnerable people outside of healthcare settings; and, police forces regulating social behaviour.

However, most (relevant) HIAP studies identify a general lack of effective intersectoral government action, related largely to a tendency towards ‘siloed’ policymaking within each department, exacerbated by ‘turf wars’ between departments (even if they notionally share the same aims) and a tendency for health departments to be low status, particularly in relation to economic departments (also note the frequently used term ‘health imperialism’ to describe scepticism about public health in other sectors).  Some studies highlight the potential benefits of ‘win-win’ strategies to persuade non-health sectors that collaboration on health equity also helps deliver their core business (e.g. Molnar et al 2015), but the wider public administration literature is more likely to identify a history of unsuccessful initiatives with a cumulative demoralising effect (e.g. Carey and Crammond, 2015; Molenveld et al, 2020).  

The pursuit of wider collaboration

HIAP ambitions extend to ‘collaborative’ or ‘co-produced’ forms of governance, in which citizens and stakeholders work with policymakers in health and non-health sectors to define the problem of health inequalities and inform potential solutions. These methods can help policymakers make sense of broad HIAP aims through the eyes of citizens, produce priorities that were not anticipated in a desktop exercise, help non-health sector workers understand their role in reducing health inequalities, and help reinforce the importance of collaborative and respectful ways of working.

An excellent example comes from Corburn et al’s (2014) study of Richmond, California’s statutory measures to encourage HIAP. They describe ‘coproducing health equity in all policies’ with initial reference to WHO definitions, but then to social justice in relation to income and wealth, which differs markedly according to race and immigration status. It then reports on a series of community discussions to identify key obstacles to health:

“For example, Richmond residents regularly described how, in the same day, they might experience or fear violence, environmental pollution, being evicted from housing, not being able to pay health care bills, discrimination at work or in school, challenges accessing public services, and immigration and customs enforcement (ICE) intimidation … Also emerging from the workshops and health equity discussions was that one of the underlying causes of the multiple stressors experienced in Richmond was structural racism. By structural racism we meant that seemingly neutral policies and practices can function in racist ways by disempowering communities of color and perpetuating unequal historic conditions” (2014: 627-8).

Yet, a tiny proportion of HIAP studies identify this level of collaboration and new knowledge feeding into policy agendas to address health equity.

The cautionary tale: HIAP does not cause health equity

Rather, most of the peer-reviewed academic HIAP literature identifies a major gap between high expectations and low implementation. Most studies identify an urgent and strong impetus for policy action to be proportionate to the size of the policy problem, and ideas about the potential implementation of a HIAP agenda when agreed, but no studies identify implementation success in relation to health equity. In fact, the two most-discussed examples – in Finland and South Australia – seem to describe a successful reform of processes that have a negligible impact on equity.  

A window of opportunity for what?

It is common in the public health field to try to identify ‘windows of opportunity’ to adopt (a) HIAP in principle, and (b) specific HIAP-friendly policy instruments. It is also common to try to identify the factors that would aid HIAP implementation, and to assume that this success would have a major impact on the social determinants of health inequalities. Yet, the cumulative experience from HIAP studies is that governments can pursue health promotion and intersectoral action without reducing health inequalities.

For me, this is the context for current studies of the unequal impact of the coronavirus across the globe and within each country. In some cases, there are occasionally promising discussions of major policymaking reforms, or to use the current crisis as an impetus for social justice as well as crisis response. Yet, the history of the pursuit of HIAP-style reforms should help us reject the simple notion that some people saying the right things will make that happen. Instead, right now, it seems more likely that – in the absence of significantly new action** – the same people and systems that cause inequalities will undermine attempts to reduce them. In other words, health equity will not happen simply because it seems like the right thing to do. Rather, it is a highly contested concept, and many people will use their power to make sure that it does not happen, even if they claim otherwise.

*These are my early thoughts based on work towards a (qualitative) systematic review of the HIAP literature, in partnership with Emily St Denny, Sean Kippin, and Heather Mitchell.

**No, I do not know what that action would be. There is no magic formula to which I can refer.

See also: Tired of science being ignored? Get political by @DrMaryTBassett

Public health policy: assumptions and expectations

Rather misleadingly, this very draft paper is called The Politics of Evidence-based ‘Health in All Policies’. It’s for Integrating Science and Politics for Public Health, convened by Patrick Fafard and Adèle Cassola at the Global Strategy Lab.

The most interesting section, for me, is the attempt to sense check the following list of assumptions/ expectations that I associate with public health studies of public policy. Unless stated otherwise, this list is based on literature reviews and documentary analysis underpinning studies of tobacco policy and prevention policy (Cairney and St Denny, 2020), as well as more impressionistic reflections from peer-reviewing many papers on this topic and attending relevant conferences (usually to speak to practitioners about the politics of EBPM). I am relying primarily on (a) the sense, often described in qualitative research, of a ‘saturation point’ to feel confident that more research will not unearth more categories, than (b) counting the frequency of term-use in each category, or (c) network analysis to identify the nature of a self-defined public health profession or community. As such, the focus is on the assumptions that scholars in this field often seem to take for granted, and often do not feel the need to explain. Its purpose is logical and conditional: if these are the assumptions, these are the expectations.

On that basis, I present a common public health narrative of the policy problem, how to understand it, and the processes necessary to address it:

• Focus on preventing ill health rather than treating it when it becomes too severe.
• Distinguish between types of prevention: primary (focus on the whole population to stop a problem occurring by investing early and/or modifying the social or physical environment); secondary (focus on at-risk groups to identify a problem at a very early stage to minimise harm); tertiary (focus on affected groups to stop a problem getting worse)
• Focus on the social determinants of health inequalities, defined by the WHO (2019) as ‘the unfair and avoidable differences in health status’ that are ‘shaped by the distribution of money, power and resources’ and ‘the conditions in which people are born, grow, live, work and age’.
• Promote ‘upstream’ measures designed to influence the health of the whole population (or health inequalities) rather than ‘downstream’ measures targeting individuals (although we discussed some debate/ confusion about the meaning of upstream).
• Use scientific evidence to identify the nature of problems and most effective solutions.
• Define scientific evidence in a particular way, such as in relation to a ‘hierarchy’ in which (a) the systematic review of randomised control trials often represents the gold standard, and (b) systems modelling plays a key role. Or, in fewer cases, challenge that hierarchy energetically.
• Promote major policymaking reforms, including a focus on holistic or joined-up government, since the responsibility for health improvement goes well beyond health departments.  Prevention (or preventive policymaking) is a classic term, and ‘health in all policies’ (HIAP) is currently a key term.
• Focus strongly on the role of industry as ‘vested interests’ causing public health problems (the ‘commercial determinants of health’) and, often, the lack of political will to regulate commercial activity.
• Treat public health and prevention as a form of social protection (new category after PHE). Often, actors describe a moral imperative to intervene (in which case, the opposite argument relates to individual responsibility and opposition to the ‘nanny state’ – see also Cairney et al, 2012 on ‘secular morality’).
• Use tobacco control as a model for other specific issues (e.g. alcohol use, obesity, salt) and the prevention agenda more generally (Studlar and Cairney, 2019).
• Focus on identifying policy changes that represent a ‘win-win’ scenario in which all parties benefit from the policy outcome (in terms of their health), rather than identifying political winners and losers from the policy choice itself (new category – Baum et al, 2014).

Such assumptions underpin expectations for the role of government, and provide a frame of reference for assessing the overall direction of policy (such as for ‘prevention’). Please let me know if there is a big missing category, or one of them doesn’t seem quite right.