Health in All Policies Toolkit

Health in All Policies as a specific term was first put forward in 2006, in a paper by a Finnish delegation during that country’s presidency of the European Union. Highlighting society’s collective responsibility for considering a population’s health (rather than just the responsibility of the health sector), the paper succeeded in putting this perspective onto the international agenda (Ståhl, Wismar, Ollila, Lahtinen, & Leppo, 2006). By 2013, Health in All Policies had become the central theme of the World Health Organization’s (WHO) 8th Global Conference on Health Promotion.

Yet, more generally, the Health in All Policies approach is a continuation of ideas developed before 2006, that took intersectoral action and healthy public policies as essential for population health, health equity and the establishment of health as a human right (WHO, 2013). For example, the approach incorporates ideas from WHO’s Ottawa Charter for Health Promotion (1986), which helped us understand that healthy public policies are a means of action to address social determinants of health and help avoid preventable diseases. WHO (1986) had also recognized previously that a population’s state of health depends not only on health care and lifestyle, but also on the conditions in which people live and work.

In keeping with these insights, Health in All Policies is a strategy proposed to all governments at all levels to uncover potential health effects of decisions from every sector. As such, it is a crucial strategy in establishing healthy public policy, which WHO (1988) sees as policy outside of public health that includes an explicit concern for the health of a population. With a Health in All Policies approach, governments can better understand health impacts and inequalities, while the public health sector can be more sensitive to the objectives of other sectors and more able to identify opportunities for collaborative practices (Kickbusch & Gleicher, 2012).

When considering healthy public policy, “policy” should be taken in a broad sense, given that it refers to laws, regulations, programs, strategies and projects at all levels of government decision-making. Understood as such, we can see how government sectors like education, transportation, urban development and revenue may affect health — both directly (through physical or psychological risk exposure) and indirectly (through encouragement or lack thereof to adopt healthy lifestyles).

Among its several types, healthy public policies can be sector-specific and driven by a predominant health-oriented motivation. Laws to reduce smoking are a good example. Other policies seek to improve or protect health but do so secondarily. A program to improve public transit, for example, reduces road congestion which, as a result, lowers air pollution and improves health. Still others, known as intersectoral policies, bring together health and non-health sectors while making health either a predominant or a secondary goal. Healthy schools and urban development are examples of this type.

Nurses can play an important role in healthy public policy. For example, by researching or sharing knowledge that contributes to a better understanding of needs and solutions, their work can inform the design of better policies. They can also help when a program or project is introduced by ensuring it responds to the needs of the target population. Numerous opportunities exist for using a “health lens” during the process of policy development. Whether a policy is at the point of being put on the political agenda or at the point of its formulation or implementation, nurses can provide a credible and important voice.

Much like environmental impact assessments, HIAs are most useful when used before the decision-making stage, as the following diagram illustrates.

Health impact assessments contribute to establishing healthy public policies (Kemm, 2001) and are a preferred tool for the Health in All Policies approach (Ståhl et al., 2006). The HIA process draws attention to potential health consequences that decision-makers in sectors like transport, finance and urban development don’t usually consider. HIAs also make recommendations that help these decision-makers prevent negative health effects and maximize positive ones.

Questions an HIA seeks to answer:

• What objectives are the decision-makers pursuing?
• What health determinants are at risk of being affected (positively or negatively) by this policy or project?
• Who will be most affected? Which population groups?
• What evidence supports the effects the project has on social determinants? What evidence supports the effects the social determinants have on health?
• What recommendations would enable decision-makers to reach their goals while keeping the population’s health in mind?

The HIA process is characterized by its standardized successive stages and by its values and guiding principles. These values include democracy (citizen participation), the ethical use of knowledge (transparency), equity and sustainable development (WHO, 1999). An HIA most effectively influences policy decisions that favour health when applied holistically (that is, when all health determinants are taken into consideration) and inclusively (when collaboration occurs with a range of partners, including citizens, decision-makers and stakeholders) (Harris-Roxas, Simpson, & Harris, 2004).

The greater concern an equity-focused health impact assessment (EFHIA) has for health inequalities stems from the gaps in the frequency and quality with which an HIA takes them into account (Harris-Roxas, Simpson, & Harris, 2004). Even though equity is a fundamental value of the HIA approach, these gaps are why equity-focused health impact assessment guides are considered necessary.

Much like an HIA, the equity-focused approach is applied to projects and public policies under development, generally within non-health sectors, prior to implementation. As with an HIA, an EFHIA is interested in the distribution of health impacts among different population groups and the differences these impacts have on each of these groups. However, the EFHIA goes further in the fight against health inequalities by passing judgment on the unfair and avoidable nature of these differences (which an HIA does not necessarily do) (Mahoney, Simpson, Harris, Aldrich, & Stewart Williams, 2004).

With an HEIA the attention is on ensuring that all members of a population have equal access to health services, public health programs and quality of care rather than on the other health determinants as they relate to a project, program or policy (Haber, 2010). Another distinguishing characteristic of an HEIA is that it can be used both before and after the implementation of a program.

The systematic use of all these assessment tools in policies, programs and projects can ensure that health inequalities are integrated into decision-making across all sectors. As a result, we can reduce health gaps or, at the very least, help prevent the further widening of health gaps between groups.