Implementation of Health 2015 public health program in Finland: a welfare state in transition

Tools for local health in all policies implementation: evidence from an explanatory case study of Kuopio, Finland

AIMS

This paper describes the use of three governance tools for health in all policies utilised to facilitate implementation in the municipality of Kuopio, Finland: impact assessments, a city mandate (the Kuopio strategy), and shared budgets.

METHODS

An explanatory case study was used. Data sources included semistructured interviews with 10 government employees and scholarly literature. Realist scientific methods were used to reveal mechanisms underlying the use of tools in health in all policies.

RESULTS

Strong evidence was found supporting initial and new theory/hypotheses regarding the use of each tool in achieving positive implementation outcomes. Impact assessments facilitated health in all policies by enhancing understanding of health implications. The Kuopio strategy aided in implementation by giving credence to health in all policies work via formal authority. Shared budgets promoted intersectoral discussions and understanding, and a sense of ownership, in addition to allowing time to be spent on health in all policies work and not financial deliberation.

CONCLUSIONS

Findings confirm the efficacious use of three governance tools in implementing health in all policies in Kuopio. Knowledge and evidence-based guidelines on local health in all policies implementation are needed as this policy approach continues to be recognised and adopted as a means to promote population health and health equity.

Factors of the policy process influencing Health in All Policies in local government: A scoping review

Objectives

This review aimed to identify factors in the policymaking environment that influence a Health in all Policies approach in local government, how these vary across different municipal contexts, and the extent that theories of the policy process are applied.

Methods

A scoping review was conducted to include sources published in English, between 2001 and 2021 in three databases, and assessed for inclusion by two blind reviewers.

Results

Sixty-four sources were included. Sixteen factors of the policy process were identified, expanding on previously reported literature to include understanding and framing of health, use of evidence, policy priority, and influence of political ideology. Eleven sources applied or referred to theories of the policy process and few reported findings based on different local government contexts.

Conclusion

There are a range of factors influencing a Health in All Policies approach in local government, although a limited understanding of how these differ across contexts. A theory-informed lens contributed to identifying a breadth of factors, although lack of explicit application of theories of the policy process in studies makes it difficult to ascertain meaningful synthesis of the interconnectedness of these factors.

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

BACKGROUND

Health in All Policies (HiAP) encompasses collaboration across government and the consideration of health in various governmental sector's policies and decisions. Despite increasing advocacy, interest, and uptake in HiAP globally, empirical and evaluative studies are underrepresented in this growing literature, particularly literature on HiAP implementation at the local level. Finland has been a pioneer in and champion for HiAP.

METHODS

A realist explanatory case study design was used to test hypotheses about how HiAP is implemented in Kuopio, Finland. Semi-structured interviews with ten government employees from various sectors were conducted. Data from interviews and literature were analyzed with the aims of uncovering explanatory mechanisms in the form of context-strategy-mechanism-outcome (CSMO) configurations related to implementation strategies. Evidence was evaluated for quality based on triangulation of sources and strength of evidence. We hypothesized that having or creating a common goal between sectors and having committed staff and local leadership would facilitate implementation.

RESULTS

Strong evidence supports our hypothesis that having or creating a common goal can aid in positive implementation outcomes at the local level. Common goals can be created by the strategies of having a city mandate, engaging in cross-sectoral discussions, and/or by working together. Policy and political elite leadership led to HiAP implementation success because leaders supported HiAP work, thus providing justification for using time to work intersectorally. How and why the wellbeing committee facilitated implementation included by providing opportunities for discussion and learning, which led to understanding of how non-health decisions impact community wellbeing, and by acting as a conduit for the communication of wellbeing goals to government employees.

CONCLUSION

At the municipal level, having or creating a common goal, leadership from policy and political elites, and the presence of committed staff can facilitate HiAP implementation. Inclusion of not only strategies for HiAP, but also the explanatory mechanisms, aids in elucidating how and why HiAP is successfully implemented in a local setting.

Policy design for territorial equity in multi-level and multi-sectoral political systems: Comparing health and education strategies

The EU has many plans to foster equity and spatial justice. However, each has separate reference points, and it is difficult to find an overall vision. To demonstrate, we analyse two sectoral strategies to identify their implications for spatial justice strategies. Education focuses on early investment and public service reform. Health prioritises intersectoral action to address the 'social determinants' beyond the control of health services. Both warn against equating territorial cohesion or spatial justice with equal access to public services. These findings could inform European Commission strategy, but it tends to respond with renewed rhetoric rather than reconsidering its approach.

How and why buy-in for health in all policies was facilitated in Ecuador: a realist case study of Plan Nacional para el Buen Vivir

Background

In 2008, Ecuador introduced Plan Nacional para el Buen Vivir (PNBV; National Plan for Good Living), which was widely recognized as a promising example of Health in All Policies (HiAP) due to the integration of policy sectors on health and health equity objectives. PBNV was implemented through three successive plans (2009–2013, 2013–2017, 2017–2021). In a time of widening global health inequities, there is growing interest in understanding how politics and governance shape HiAP implementation. The objective of this study was to test specific hypotheses about how, why, to what extent, and under what circumstances HiAP was implemented in Ecuador.

Methods

An explanatory case study approach (HiAP Analysis using Realist Methods on International Case Studies—HARMONICS) was used to understand the processes that hindered or facilitated HiAP implementation. Realist methods and systems theory were employed to test hypotheses through analysis of empirical and grey literature, and 19 key informant interviews. This case study focused on processes related to buy-in for a HiAP approach by diverse policy sectors, particularly in relation to the strong mandate and transformative governance approach that were introduced by then-President Rafael Correa’s administration to support PNBV.

Results

The mandate and governance approach of the HiAP approach achieved buy-in for implementation across diverse sectors. Support for the hypotheses was found through direct evidence about buy-in for HiAP implementation by policy sectors; and indirect evidence about allocation of governmental resources for HiAP implementation. Key mechanisms identified included: influence of political elites; challenges in dealing with political opposition and ‘siloed’ ways of thinking; and the role of strategies and resources in motivating buy-in.

Conclusion

In Ecuador, political elites were a catalyst for mechanisms that impacted buy-in and government funding for HiAP implementation. They raised awareness among policy sectors initially opposed to PNBV about the rationale for changing governance practices, and they provided financial resources to support efforts related to PNBV. Specific mechanisms help explain these phenomena further. Future studies should examine ways that PNBV may have been an impediment to health equity for some marginalized groups while strengthening HiAP implementation.

Theory-based capacity building intervention for intersectoral action for health at local governments: An exploratory pilot study

Aim

To design, implement and evaluate a nurse‐led capacity building intervention (PromoGOB) for intersectoral action for health at local governments.

Design

The programme was based on theories of the policy process and organizational change and facilitated by a nurse developing a health broker role. A complex intervention perspective was adopted in carrying out the study. The intervention was evaluated using a mixed method embedded design.

Methods

Quantitative component relied on a specific questionnaire. This tool, designed and piloted ad hoc, measured the capacity in terms of knowledge, awareness, resources, skills, and commitment, both at sectoral and government levels. For the qualitative component, semi‐structured interviews were conducted. These explored the perceived capacity and feasibility and acceptability issues. The programme was initiated at the end of October 2019, and it lasted a total of 5 weeks. Nineteen individuals representing various sectors at a local government in northern Spain participated in the study. The data analysis was concluded by the end of March 2020.

Findings

PromoGOB positively influenced participants' capacity for addressing health promotion. Awareness component, intersectoral work and the nurse as health broker were essential in the programme. The necessity of political participation was identified as an issue to be prioritized in future studies.

Conclusion

This study highlights the relevance of capacity building at local governments and the role that nurses can play in it. Further work should be undertaken to continue developing Health in All Policies approach at local level.

Impact

This study offers a starting point for nurses to get involved in the policy process of health promotion, performing a specific role as health brokers, building capacity at local governments for addressing social determinants of health, and delving into theories and concepts of the Health in All Policies field.

'Health in All Policies'-A Key Driver for Health and Well-Being in a Post-COVID-19 Pandemic World

Policy in all sectors affects health, through multiple pathways and determinants. Health in all policies (HiAP) is an approach that seeks to identify and influence the health and equity impacts of policy decisions, to enhance health benefits and avoid harm. This usually involves the use of health impact assessment or health lens analysis. There is growing international experience in these approaches, and some countries have cross-sectoral governance structures that prioritize the assessment of the policies that are most likely to affect health. The fundamental elements of HiAP are inter-sectoral collaboration, policy influence, and holistic consideration of the range of health determinants affected by a policy area or proposal. HiAP requires public health professionals to invest time to build partnerships and engage meaningfully with the sectors affecting the social determinants of health and health equity. With commitment, political will and tools such as the health impact assessment, it provides a powerful approach to integrated policymaking that promotes health, well-being, and equity. The COVID-19 pandemic has raised the profile of public health and highlighted the links between health and other policy areas. This paper describes the rationale for, and principles underpinning, HiAP mechanisms, including HIA, experiences, challenges and opportunities for the future.

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

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

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

Background: 'Health in All Policies' (HiAP) describes the pursuit of health equity. It has five main elements: treat health as a human right; identify evidence of the 'social determinants' of health inequalities, recognise that most powers to affect health are not held by health departments, promote intersectoral policymaking and collaboration inside and outside of government, and generate political will. Studies describe its potential but bemoan a major implementation gap. Some HiAP scholars learn from policymaking research how to understand this gap, but the use of policy theories is patchy. In that context, our guiding research question is: How does HiAP research use policy theory to understand policymaking? It allows us to zoom-out to survey the field and zoom-in to identify: the assumed and actual causes of policy change, and transferable lessons to HiAP scholars and advocates. Methods: Our qualitative systematic review (two phases, 2018 and 2020) identified 4972 HiAP articles. Of these, 113 journal articles (research and commentary) provide a non-trivial reference to policymaking (at least one reference to a policymaking concept). We use the 113 articles to produce a general HiAP narrative and explore how the relatively theory-informed articles enhance it. Results: Most articles focus on policy analysis (identifying policy problems and solutions) rather than policy theory (explaining policymaking dynamics). They report a disappointing gap between HiAP expectations and policy outcomes. Theory-informed articles contribute to a HiAP playbook to close that gap or a programme theory to design and evaluate HiAP in new ways.   Conclusions: Few HiAP articles use policy theories for their intended purpose. Policy theories provide lessons to aid critical reflection on power, political dilemmas, and policymaking context. HiAP scholars seek more instrumental lessons, potentially at the cost of effective advocacy and research.

How and why do win-win strategies work in engaging policy-makers to implement Health in All Policies? A multiple-case study of six state- and national-level governments

Background

Much of the research about Health in All Policies (HiAP) implementation is descriptive, and there have been calls for more evaluative evidence to explain how and why successes and failures have occurred. In this cross-case study of six state- and national-level governments (California, Ecuador, Finland, Norway, Scotland and Thailand), we tested hypotheses about win–win strategies for engaging policy-makers in HiAP implementation drawing on components identified in our previous systems framework.

Methods

We used two sources of data — key informant interviews and peer-reviewed and grey literature. Using a protocol, we created context–mechanism–outcome pattern configurations to articulate mechanisms that explain how win–win strategies work and fail in different contexts. We then applied our evidence for all cases to the systems framework. We assessed the quality of evidence within and across cases in terms of triangulation of sources and strength of evidence. We also strengthened hypothesis testing using replication logic.

Results

We found robust evidence for two mechanisms about how and why win–win strategies build partnerships for HiAP implementation — the use of shared language and the value of multiple outcomes. Within our cases, the triangulation was strong, both hypotheses were supported by literal and contrast replications, and there was no support against them. For the third mechanism studied, using the public-health arguments win–win strategy, we only found evidence from Finland. Based on our systems framework, we expected that the most important system components to using win–win strategies are sectoral objectives, and we found empirical support for this prediction.

Conclusions

We conclude that two mechanisms about how and why win–win strategies build partnerships for HiAP implementation — the use of shared language and the value of multiple outcomes — were found as relevant to the six settings. Both of these mechanisms trigger a process of developing synergies and releasing potentialities among different government sectors and these interactions between sectors often work through sectoral objectives. These mechanisms should be considered when designing future HiAP initiatives and their implementation to enhance the emergence of non-health sector policy-makers’ engagement.

"First, Do No Harm": Have the Health Impacts of Government Bills on Tax Legislation Been Assessed in Finland?

As taxation is one of the key public policy domains influencing population health, and as there is a legal, strategic, and programmatic basis for health impact assessment (HIA) in Finland, we analyzed all 235 government bills on tax legislation over the years 2007–2014 to see whether the health impacts of the tax bills had been assessed. We found that health impacts had been assessed for 13 bills, bills dealing with tobacco, alcohol, confectionery, and energy legislation and that four of these impact assessments included impacts on health inequalities between social classes. Based on our theoretical classification, the health impacts of 40 other tax bills should have been evaluated.

Evaluating Health in All Policies Comment on "Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia"

Health in All Policies (HiAP) has gained attention as a potential tool to address complex health and societal challenges at global, regional, national and subnational levels. In a recent article, Lawless et al propose an evaluation framework developed in the context of the South Australia HiAP initiative. Strategies, mediators, activities and impacts identified in the framework could potentially be useful for evaluating HiAP in other settings. Creating and sustaining political will, managing conflicts of interest and achieving financially, politically and conceptually sustainable HiAP initiatives are challenges that could be further strengthened in the current framework.

Ideas for Extending the Approach to Evaluating Health in All Policies in South Australia Comment on "Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia"

Since 2008, the government of South Australia has been using a Health in All Policies (HiAP) approach to achieve their strategic plan (South Australia Strategic Plan of 2004). In this commentary, we summarize some of the strengths and contributions of the innovative evaluation framework that was developed by an embedded team of academic researchers. To inform how the use of HiAP is evaluated more generally, we also describe several ideas for extending their approach, including: deeper integration of interdisciplinary theory (eg, public health sciences, policy and political sciences) to make use of existing knowledge and ideas about how and why HiAP works; including a focus on implementation outcomes and using developmental evaluation (DE) partnerships to strengthen the use of HiAP over time; use of systems theory to help understand the complexity of social systems and changing contexts involved in using HiAP; integrating economic considerations into HiAP evaluations to better understand the health, social and economic benefits and trade-offs of using HiAP.

The implementation of Health in All Policies initiatives: a systems framework for government action

BACKGROUND

There has been a renewed interest in broadening the research agenda in health promotion to include action on the structural determinants of health, including a focus on the implementation of Health in All Policies (HiAP). Governments that use HiAP face the challenge of instituting governance structures and processes to facilitate policy coordination in an evidence-informed manner. Due to the complexity of government institutions and the policy process, systems theory has been proposed as a tool for evaluating the implementation of HiAP.

METHODS

Our multiple case study research programme (HiAP Analysis using Realist Methods On International Case Studies - HARMONICS) has relied on systems theory and realist methods to make sense of how and why the practices of policy-makers (including politicians and civil servants) from specific institutional environments (policy sectors) has either facilitated or hindered the implementation of HiAP. Herein, we present a systems framework for the implementation of HiAP based on our experience and empirical findings in studying this process.

RESULTS

We describe a system of 14 components within three subsystems of government. Subsystems include the executive (heads of state and their appointed political elites), intersectoral (the milieu of policy-makers and experts working with governance structures related to HiAP) and intrasectoral (policy-makers within policy sectors). Here, HiAP implementation is a process involving interactions between subsystems and their components that leads to the emergence of implementation outcomes, as well as effects on the system components themselves. We also describe the influence of extra-governmental systems, including (but not limited to) the academic sector, third sector, private sector and intergovernmental sector. Finally, we present a case study that applies this framework to understand the implementation of HiAP - the Health 2015 Strategy - in Finland, from 2001 onward.

CONCLUSIONS

This framework is useful for helping to explain how, why and under what circumstances HiAP has been successfully and unsuccessfully implemented in a sustainable manner. It serves as a tool for researchers to study this process, and for policy-makers and other public health actors to manage this process.