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

Case studies: healthcare, public health, mental health #POLU9SP

This is the second of three posts which use case studies of cross-cutting and specific policy areas to add more depth to our discussion of Scottish politics and policymaking.

Most aspects of health policy have been devolved since 1999, and many were devolved before 1999, so we can generate a relatively long term picture of policy change/ divergence in three key areas: healthcare, mental health, and public health. We can then revisit the idea of prevention and inequalities raised in the first lecture.

Healthcare

The NHS has always been a little bit different in Scotland, which enjoyed administrative devolution – through the Scottish Office (a UK Government Department) – before 1999 and maintained its own links with professional groups.

Scotland has traditionally trained a disproportionate number of UK doctors and maintained an unusually high presence of Royal Colleges. This greater medical presence boosted the Scottish Office’s policymaking image as ‘professionalised’, or more likely to pursue policies favoured by the medical profession than the UK’s Department of Health. For example, it appeared to be less supportive of reforms based on the ‘marketisation’ of the NHS.

Devolution turbo boosted this sense of Scottish policy difference (see the Greer and Jarman discussion).

For example, while the UK Labour Government furthered the ‘internal market’ established by its Conservative predecessors, the Labour-led Scottish Government seemed to dismantle it (for example, there are no Foundation hospitals). It also bought (and effectively renationalised) a private hospital, which had a symbolic importance way above its practical effect.

Since 2007, the SNP-led Scottish Government – often supported publicly by UK-wide groups such as the British Medical Association (and nursing and allied health professions) – has gone big on this difference between Scottish and UK Government policies, criticising the marketization of the NHS in England and expressing, at every opportunity, the desire to maintain the sort of NHS portrayed by Danny Boyle at the Olympics opening ceremony.

This broad approach is generally supported, at least implicitly, by the important political parties in Scotland (the SNP is competing with a centre-left Labour Party and the Conservatives are less important). It is also supported by a medical profession and a public that, in practice, tends to be more committed to the NHS (in other words, opinion polls may not always show a stark difference in attitudes, but there is not the same fear in Scotland, as in the South-East of England, that doctors and patients might defect to the private sector if the NHS is not up to scratch).

Public health

Scotland won the race to ban smoking in public places and is currently trying to introduce a minimum unit price for alcohol. It has also placed particular emphasis on the wider determinants of health and made the right noises about the balance between public health and acute care. However, there are also major similarities in Scottish and UK Government approaches. For example, the UK tops the European league table on comprehensive tobacco control (and England/ Wales beat Scotland to ban smoking in cars with children).

Mental health

To some extent, early Scottish Governments developed an international reputation for innovation in some areas relating to wellbeing. It also reformed mental health and capacity legislation in a relatively quick and smooth way – at least compared to the UK Labour Government, which had a major stand-off with virtually all mental health advocacy groups on psychiatric-based reforms. Part of the difference relates to the size of Scotland and its government’s responsibilities which can produce a distinctive policy style; it often has the ability to coordinate cross-cutting policy, in consultation with stakeholders, in a more personal way. However, this is a field in which there tend to be often-similar policies beyond the Sun-style headlines.

The bigger picture of continuity: a tax funded service

These Scottish-UK differences should be seen in the context of a shared history and some major similarities. Both NHS systems are primarily tax-funded and free at the point of use, with the exception of some charges in England (which should not be exaggerated – for example, 89% of prescriptions in England are tax-funded). Both governments have sought to assure the public in similar ways by, for example, maintaining high profile targets on waiting times. Both systems face similar organisational pressures, such as the balance between a public demand for local hospitals and medical demand for centralised services. Both governments face similar demographic changes which put pressure on services. Both have similarly healthy (or unhealthy) populations.

The bigger picture of prevention and health inequality

Although the Scottish Government pursues an agenda on prevention to reduce service demand and health inequalities, many other policies based on the idea of universal provision have the potential to exacerbate inequalities.

For example, a real rise in spending (cash spending adjusted with the GDP deflator) on health policy of 68% from 2000-11 did not have a major effect on health inequalities (Cairney and McGarvey, 2013: 229). Instead, Scottish Governments tended to use the money in areas such as acute care to, for example, maintain high profile waiting list (non-emergency operations) and waiting times (A&E) targets which did not have a health inequalities component (Cairney, 2011: 177-9). It has also phased out several charges, such on prescriptions and eye tests, which increase spending without decreasing inequalities (particularly since the lowest paid already qualified for exemptions for charges).

It has pursued strongly a public health strategy geared, in part, towards reducing health inequalities, but with the same tendency as in the UK for healthcare to come first. This process includes interesting overlaps in aims and outcomes, such as in tobacco control where smoking is addressed strongly partly because it represents the single biggest element of health inequalities, but most initiatives do not necessarily reduce inequalities in smoking.

Further Reading

I discuss these issues in more depth in Scottish Politics and The Scottish Political System Since Devolution. See also this draft chapter on prevention and health policy by the Scottish and UK Governments

 

After the War on Tobacco, Is a War on Alcohol Brewing?*

The United Kingdom now has one of the most comprehensive tobacco control policies in the world, a far cry from its status two decades ago. Some influential public health voices have called for a similar campaign against alcohol consumption. But is the comparison appropriate? We identify the factors which were important in the relatively successful campaign for tobacco control, then analyse the obstacles and opportunities facing the movement for more stringent alcohol control. Alcohol policy today bears a striking resemblance to tobacco policy pre-1990s, when the UK started on its path to becoming a major regulatory state in the world. Can alcohol policy be changed in a similar way?

Paper here  Cairney Studlar 2014 WMHP Alcohol and Tobacco Policy UK

See also – https://paulcairney.wordpress.com/public-health/

See also: http://blogs.lse.ac.uk/impactofsocialsciences/2013/07/16/evidence-matters-tobacco-and-alcohol-comparison/

*We submitted the paper to a US journal, where this framing is more normal. The idea of a public health crusade is also in good currency in some libertarian circles.

The WHO Framework Convention for Tobacco Control (FCTC): What would have to change to ensure effective policy implementation?*

Background
The World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) is one of the most widely accepted treaties in the United Nations system. It represents an attempt by governments to address the global tobacco epidemic. It contains a ‘comprehensive’ set of measures to reduce the demand for, and supply of, tobacco products worldwide. In most countries, it has prompted an increase in the number and depth of policy instruments. It primarily sets the agenda for change rather than providing the means to ensure the domestic implementation of policy. Implementation has been uneven; it is more evident in ‘developed’ than ‘developing’ countries. We identify the policy processes that would have to change to ensure more successful global implementation.
Results
The number of policies adopted across the globe has increased markedly since the negotiation of the FCTC. However, the implementation of policy has been uneven. The developed-developing country distinction provides an important way to describe this outcome, since most progress has been made in developed countries. However, it does not explain the uneven implementation of the FCTC; ‘development’ is not the causal factor. We synthesise the public policy literature to identify the key causal factors [1]. We identify the most relevant characteristics of the policy processes within ‘leading’ countries with the most comprehensive tobacco control: their department of health has taken the policy lead (replacing trade and treasury departments); tobacco is ‘framed’ as a pressing public health problem (not an economic good); public health groups are more consulted (often at the expense of tobacco companies); socioeconomic conditions (including the value of tobacco taxation, and public attitudes to tobacco control) are conducive to policy change; and, the scientific evidence on the harmful effects of smoking and secondhand smoking are ‘set in stone’ within governments. These factors tend to be absent in the countries with limited controls. We argue that, in the absence of these wider changes in their policy environments, the countries most reliant on the FCTC are currently the least able to implement it.

The long version of the paper is here: Cairney Mamudu 2013 Implementing the FCTC_ Insights From Public Policy

See also

https://paulcairney.wordpress.com/public-health/

Global Tobacco Control

Alcohol: the Harmful versus Healthy Debate

http://blogs.lse.ac.uk/politicsandpolicy/archives/34735

Related articles

• After the War on Tobacco, Is a War on Alcohol Next?* (paulcairney.wordpress.com)