HIAP Framework_version 2

7/27/2019 HIAP Framework_version 2

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Health in All Policies

framework for countryaction

2nd

Draft January 2013

Meri Koivusalo, THL, Finland

Comments received so far: Timo Stahl, KC Tang, Pekka Puska, Taru Koivisto, Eeva Ollila, Ilona

Kickbusch, Rodriguez Lucero, Jim Ball, Benjamin Mason Meier, Mark Phillips, Gerry Gallagher, Mana

Harel, David Hueto and participants of October 2012 Scientific Committee meeting.


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Contents

1. Purpose of this framework ................................................................................................................. 3

1.1 HiAP and health promotion .......................................................................................................... 3

1.2 Why HiAP?..................................................................................................................................... 4

2. Roots of Health in All Policies ............................................................................................................. 5

2.1. How do we define Health in All Policies (HiAP)? ......................................................................... 6

2.2. How does Health in All Policies relate to other terms and definitions ........................................ 7

2.2.1. Intersectoral action and whole-of-government approach ................................................... 7

2.2.2. Cooperation and joined up government policies ................................................................. 8

2.2.3. Multisectoral action .............................................................................................................. 8

3. Achieving Health in all Policies ............................................................................................................ 9

3.1. Prioritisation and focus ................................................................................................................ 9

3.2. Governance for Health in All Policies ......................................................................................... 11

3.2.1. Legitimacy ........................................................................................................................... 12

3.2.2. Accountability ..................................................................................................................... 12

3.2.3. Public participation ............................................................................................................. 13

3.2.4 Co-benefits, mutual interests and conflicts of interests ...................................................... 13

4. Action for Health in All Policies ......................................................................................................... 15

4.1. Public administration and executive .......................................................................................... 15

4.2 Implementing HIAP within national public administration (executive) ...................................... 15

4.3. HiAP in the legislature and decision-making process ................................................................ 18

4.4. Civil society and private sector .................................................................................................. 20

4.5. Regional or local policymaking................................................................................................... 23

4.6. Reaching out - policy alliances for HiAP ..................................................................................... 23

5. Knowledge and training for HiAP ...................................................................................................... 24

6. Global action for HiAP ....................................................................................................................... 27

7. Moving towards Health in All Policies ............................................................................................... 29

7.1. At national level ......................................................................................................................... 29

7.2. Globally ...................................................................................................................................... 31


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1. Purpose of this framework

A Health in All Policies (HiAP) approach builds on previous health promotion conferences, in

particular with respect to the Ottawa Charter for health promotion in 19861

and the Adelaide

recommendations on healthy public policies2. It emphasizes that public policies and decisions made

in regard to policy areas other than health (e.g. transport, agriculture, education, employment etc.)

have a significant impact on citizens health, on equity and health determinants and on the capacity

of health systems to respond to health needs. This implies that accountability for health, equity in

health, health systems functioning and for health protection and promotion needs to take place as

part of broader policy making and may not remain solely with the health sector.

The purpose of this framework is to give guidance on different ways to enhance the Health in All

Policies (HiAP) approach, in particular, at national level. It is recognised that policies do not

necessarily take place in a purely national context.3

Many Member States have delegated powers to

federal, regional or local actors at subnational level. While this framework has its focus on national

policies, HiAP seeks to address public policies at the level where respective decisions are made,

including local, regional, national and global levels of decision-making. Furthermore, the focus on

national framework can easily be applied in the context of federal or state governance in countries

where crucial public policy decisions are not made at national level. HIAP is thus not restricted to a

particular level of governance, but can and needs to be accommodated to the level on which

decisions are made.

1.1 HiAP and health promotion

HiAP is integral to health promotion and builds on the continuum of healthy public policies. It is a

response, in particular, to challenges of addressing policies in other sectors. However, it is necessaryto emphasise that it is not an alternative or replacement for other health promotion strategies

4,

health education, public health measures or other health programmes and work within the health

sector, but provides governments with the means to tackle such health determinants and complex

policy challenges that are the result of policy decisions in other sectors than health and may not be

tackled on the basis of health sector or health policies alone

The Health in All Policies approach recognises that governments have many priorities.

Implementation of the approach does not automatically imply that health policy priorities gain

precedence over and above other policy aims, but essentially that when decisions relevant to health

or health policy are made in other policy areas, health considerations will be duly taken into account.

1Ottawa Charter on Health Promotion is available:

http://www.who.int/healthpromotion/conferences/previous/ottawa/en/2

Adelaide recommendations on healthy public policies is available:

http://www.who.int/healthpromotion/conferences/previous/adelaide/en/index1.html3

Decisions can be made at supranational level as part of global policy making or at regional structures. These

decisions are often shaped by national policies in other sectors. While this framework is for national policies it

can be used and adapted also for supranational level decision-making and governance structures, such as

European Union.4

Ottawa charter, for example, elaborates five core areas of work, including building healthy public policy,creating supportive environments, strengthening community action, developing personal skills and reorienting

health services.
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/http://www.who.int/healthpromotion/conferences/previous/ottawa/en/http://www.who.int/healthpromotion/conferences/previous/ottawa/en/


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A key to the HiAP approach is to address policy implications at the level where policy decisions are

made or could be, but are not made, thus reaching from local to global level policy processes.

1.2 Why HiAP?

Substantial health benefits can be gained from policies or policy changes in other sectors. For

example, it has been estimated that environmental risk factors play a role in more than 80% of the

diseases regularly reported by the World Health Organization5. Other policies can have a direct

impact on health, affect social and environmental determinants of health or how health systems

function. Addressing health may also have substantial co-benefits for other policies. For example,

healthier children will be able to learn better at school. Other sectors may also face similar

challenges as health and provide a ground for alliances. Working together with other sectors can

provide further substantial gains not only in understanding the broader context from which health

problems arise, but also from practices and experiences in, for example, environment, transport or

the broader aims of poverty reduction. HiAP forms part of an effective governance that seeks to

contribute to social and economic development through a more comprehensive understanding of

the implications of policy decisions as these affect population health, equity and health systems. In

spite of this HiAP is not without costs, or a simple means for cost-containment within health care

systems. Implementation of Health in All Policies needs a critical mass of personnel and resources,

but these requirements remain modest in the context of human resources for health and overall

spending. HIAP thus needs to be understood as part of broader and overall investments in public

health, public health infrastructure and health systems management, within countries.

Furthermore, even when there would be negative implications and HiAP would not lead to changes

in policy-decisions, it can provide essential information for mitigation and improved and better

resourced response to potential risks or negative impacts from decisions in other sectors as result of

bringing these up at the time when decisions are made. This is particularly important in situations

when policy decisions are made at national level of governance, while health impacts or additional

health sector costs are realised at a lower level of governance. HiAP can thus potentially improve

transparency of policy-making not only across sectors, but also at different levels of governance.

HiAP is based on the assumption that governments have a responsibility for the health of their peo-

ples which can be fulfilled only by the provision of adequate health and social measures. This ac-

countability is expressed in the WHO Constitution and applies to all countries. HiAP is focussed on

public policies. While it does not exclude adoption of similar policies or application of similar tools in

the private sector or in public partnerships with the private sector, it does not directly address poli-

cies that corporations or private institutions define for themselves and is applicable to these only to

the extent that adoption of particular policies within the private sector is encouraged or required by

public policies.

Finally, the role of the health sector is crucial for Health in All Policies. The health administration

needs to know about health implications or health policy priorities so as to be able to communicate

with other sectors. In addition to enhancing cooperation for health, they need to be able to

contribute and participate on their behalf in intersectoral and joint activities led by other sectors.

5Source:http://www.who.int/quantifying_ehimpacts/publications/preventingdisease/en/index.html
http://www.who.int/quantifying_ehimpacts/publications/preventingdisease/en/index.htmlhttp://www.who.int/quantifying_ehimpacts/publications/preventingdisease/en/index.htmlhttp://www.who.int/quantifying_ehimpacts/publications/preventingdisease/en/index.htmlhttp://www.who.int/quantifying_ehimpacts/publications/preventingdisease/en/index.html


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2. Roots of Health in All Policies

Health in All Policies (HiAP) draws from national and international developments in the area of

health policy and comprehensive health care. It draws from obligations set as part of WHO

constitution, emphasising that: The enjoyment of the highest attainable standard of health is one of

the fundamental rights of every human being without distinction of race, religion, political belief,

economic or social condition. The Alma Ata Declaration in 19786

emphasised that: health is a

fundamental human right and that the attainment of the highest possible level of health is a most

important worldwide social goal whose realization requires the action of many other social and

economic sectors in addition to the health sector. In primary health care it was also further

elaborated in Paragraph 4of the Alma Ata Declaration, that this: " involves, in addition to the health

sector, all related sectors and aspects of national and community development, in particular

agriculture, animal husbandry, food, industry, education, housing, public works, communications and

other sectors; and demands the coordinated efforts of all those sectors".

In the field of health policy it further draws from health promotion efforts and conferences, in

particular healthy public policies and the Ottawa conference7

on health promotion and its charter,

which emphasised that: Health promotion goes beyond health care. It puts health on the agenda of

policy makers in all sectors and at all levels, directing them to be aware of the health consequences

of their decisions and to accept their responsibilities for health.

HiAP further accords with more recent developments in the context of social determinants of health

and the Rio Political Declaration,8which recognised that: Good health requires a universal,

comprehensive, equitable, effective, responsive and accessible quality health system. But it is also

dependent on the involvement of and dialogue with other sectors and actors, as their performance

has significant health impacts.

In addition to commitments as part of health policies, focus on Health in All Policies draws from

international commitments in the context of the Universal Declaration of Human Rights9and the

wide array of other civil, economic, political and social rights.10

With the right to health recognised as

part of the WHO constitution,11

health-related rights have been established in, among other treaties,

the Convention on the Rights of the Child (CRC)12

and regional agreements and mechanisms.13

While

6Alma Ata Declaration (1978). Available from:

http://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdf7

Ottawa Charter on Health Promotion (1986).Available from:http://www.who.int/healthpromotion/conferences/previous/ottawa/en/8Rio Political Declaration (2011). Available from:

http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdf9

Universal Declaration of Human Rights (1948): Available from:

http://www.un.org/en/documents/udhr/10

International General Comment 14 to the International Covenant of Economic, Social and Cultural Rights

(2000) Available from:

http://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.En 11

WHO constitution (1946) Available from:http://www.who.int/governance/eb/who_constitution_en.pdf

http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf12

Convention on the Rights of the Child (1989)Available from:

http://www2.ohchr.org/english/law/crc.htm13African Charter on Human and Peoples Rights (1986); European Social Charter (1961). On human rights and

health see:http://www.who.int/hhr/en/index.html
http://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdfhttp://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdfhttp://www.who.int/healthpromotion/conferences/previous/ottawa/en/http://www.who.int/healthpromotion/conferences/previous/ottawa/en/http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdfhttp://www.who.int/sdhconference/declaration/Rio_political_declaration.pdfhttp://www.un.org/en/documents/udhr/http://www.un.org/en/documents/udhr/http://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.Enhttp://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.Enhttp://www.who.int/governance/eb/who_constitution_en.pdfhttp://www.who.int/governance/eb/who_constitution_en.pdfhttp://www.who.int/governance/eb/who_constitution_en.pdfhttp://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdfhttp://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdfhttp://www2.ohchr.org/english/law/crc.htmhttp://www2.ohchr.org/english/law/crc.htmhttp://www.who.int/hhr/en/index.htmlhttp://www.who.int/hhr/en/index.htmlhttp://www.who.int/hhr/en/index.htmlhttp://www.who.int/hhr/en/index.htmlhttp://www2.ohchr.org/english/law/crc.htmhttp://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdfhttp://www.who.int/governance/eb/who_constitution_en.pdfhttp://www.unhchr.ch/tbs/doc.nsf/%28symbol%29/E.C.12.2000.4.Enhttp://www.un.org/en/documents/udhr/http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdfhttp://www.who.int/healthpromotion/conferences/previous/ottawa/en/http://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdf


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not all countries are members of all international conventions, many countries have included specific

commitments with respect to the right to health as part of their constitutions. For example, in South

Africa, Section 27 of the national constitution has a section on health.14

Another type of

commitment is present in the European Union treaties, in the way of recognition of a high level of

health protection in all policies in Article 168 of the Treaty of Lisbon.15

Health is highly valued by citizens across countries. The intrinsic value of HiAP is set in terms of

improved health and well-being.16

This will be at the core of the benefits for decision-makers, which

will accrue from not only supporting policy developments which will enhance and protect health and

well-being, but as well, in recognising early such policies, which can affect health, be able to address

and mitigate implications of these policies on health and health systems.

2.1. How do we define Health in All Policies (HiAP)?

The Health in All Policies (HiAP) is based on understanding that improvements in population health

and action on social determinants of health may not be achieved by a focus on health sector policies

alone, but requires action across different policy fields. Furthermore, it recognises that focus on

health sector alone is not sufficient to ensure equitable access to health services, health protection

and management of the financial sustainability of health care systems.

Different forms of policies under the title of Health in All Policies been adopted already in many

countries. Health in All Policies became more coherently articulated as part of European Union

policies during the Finnish presidency of the European Union in 200617

with all Member States

agreeing with Council Conclusions on Health in All Policies18

.In 2010 South Australia hosted the

Adelaide meeting focussing on Health in All Policies.19

California State in the United States created a

Health in All Policies task-force in 2010.20In some countries, such as Canada, HiAP has been used for

time-limited cross-sectoral policy initiatives and intersectoral action aimed at improving health at

provincial level.21

In other countries HiAP-oriented policies have been enacted without active

consideration that these are implementations of a Health in All Policies approach. Furthermore,

governments may have adopted some aspects of HiAP as part of enhancing health impact

assessments through national legislation, adopting intersectoral action or establishing broader

committee work and legislation in support of tackling Health in All Policies.

14South Africa constitution (1996). Available from:

http://www.info.gov.za/documents/constitution/1996/96cons2.htm/96cons2.htm#2715

The Lisbon Treaty (2007) Available from:http://www.lisbon-treaty.org/wcm/the-lisbon-treaty.html16

Health and well-being are increasingly considered combined in recognition that health is not only absence of

disease. While this framework is using only health, it is based on broad understanding of health, including

mental health and well-being.17

See, Presidency book on Health in All Policies:

http://ec.europa.eu/health/archive/ph_information/documents/health_in_all_policies.pdf18

Council conclusions on Health in All Policies, see:

http://www.consilium.europa.eu/ueDocs/cms_Data/docs/pressData/en/lsa/91929.pdf; European

Commission, see:http://ec.europa.eu/health/health_policies/policy/index_en.htm19

Adelaide Statement (2010)http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf20

Health in All Policies Fact Sheet (2010) Available from:

http://sgc.ca.gov/hiap/docs/about/background/HiAP_fact_sheet.pdf21See, for example:http://www.cihr-irsc.gc.ca/e/43794.html, for a critical assessment on Health in All Policies

in Canada, see:http://journal.cpha.ca/index.php/cjph/article/view/2691/2530
http://www.info.gov.za/documents/constitution/1996/96cons2.htm/96cons2.htm#27http://www.info.gov.za/documents/constitution/1996/96cons2.htm/96cons2.htm#27http://www.lisbon-treaty.org/wcm/the-lisbon-treaty.htmlhttp://www.lisbon-treaty.org/wcm/the-lisbon-treaty.htmlhttp://ec.europa.eu/health/archive/ph_information/documents/health_in_all_policies.pdfhttp://ec.europa.eu/health/archive/ph_information/documents/health_in_all_policies.pdfhttp://www.consilium.europa.eu/ueDocs/cms_Data/docs/pressData/en/lsa/91929.pdfhttp://www.consilium.europa.eu/ueDocs/cms_Data/docs/pressData/en/lsa/91929.pdfhttp://ec.europa.eu/health/health_policies/policy/index_en.htmhttp://ec.europa.eu/health/health_policies/policy/index_en.htmhttp://ec.europa.eu/health/health_policies/policy/index_en.htmhttp://www.who.int/social_determinants/hiap_statement_who_sa_final.pdfhttp://www.who.int/social_determinants/hiap_statement_who_sa_final.pdfhttp://www.who.int/social_determinants/hiap_statement_who_sa_final.pdfhttp://sgc.ca.gov/hiap/docs/about/background/HiAP_fact_sheet.pdfhttp://sgc.ca.gov/hiap/docs/about/background/HiAP_fact_sheet.pdfhttp://www.cihr-irsc.gc.ca/e/43794.htmlhttp://www.cihr-irsc.gc.ca/e/43794.htmlhttp://www.cihr-irsc.gc.ca/e/43794.htmlhttp://journal.cpha.ca/index.php/cjph/article/view/2691/2530http://journal.cpha.ca/index.php/cjph/article/view/2691/2530http://journal.cpha.ca/index.php/cjph/article/view/2691/2530http://journal.cpha.ca/index.php/cjph/article/view/2691/2530http://www.cihr-irsc.gc.ca/e/43794.htmlhttp://sgc.ca.gov/hiap/docs/about/background/HiAP_fact_sheet.pdfhttp://www.who.int/social_determinants/hiap_statement_who_sa_final.pdfhttp://ec.europa.eu/health/health_policies/policy/index_en.htmhttp://www.consilium.europa.eu/ueDocs/cms_Data/docs/pressData/en/lsa/91929.pdfhttp://ec.europa.eu/health/archive/ph_information/documents/health_in_all_policies.pdfhttp://www.lisbon-treaty.org/wcm/the-lisbon-treaty.htmlhttp://www.info.gov.za/documents/constitution/1996/96cons2.htm/96cons2.htm#27


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While there are already a variety of national frameworks and versions for HiAP,22

the definition used

in this framework is framed so as to give guidance on what can be understood as HiAP and how a

broader scope for HiAP could be utilised, reaching in particular into policy processes and

mechanisms for improving accountability for health as well as how to differentiate between

different terminologies. In practice many aspects of HiAP seem to have been considered or

implemented predominantly as part of local policies and local government work, which was

reflected also in the 2010 Adelaide conference and statement on HiAP23

.

Health in All policies approach seeks to ensure that potential implications to population health,

health equity and health systems are taken into account in other public policies and policy-making,

at the level decisions made, so as to realize health-related rights and obligations. In addition, it seeks

to improve accountability for decision-making in health. At national level Health in All Policies would

thus extend from public administration and the executive (government) to the legislature

accountable for legislation, budget and taxation (parliament/congress/national assembly).

2.2. How does Health in All Policies relate to other terms and definitions

2.2.1. Intersectoral action and whole-of-government approach

Co-operation across different government sectors is often described with the term intersectoral

action, although the terms intersectoral and multisectoral are also used to refer to collaboration

with private and non-governmental sectors. The Health in All Policies approach is for public policies

and while it includes different forms of intersectoral action, Health in All Policies is applicable not

only to the administration and executive (ministers), but also to the legislature (parliament).

Similarly, HiAP is often carried out in accordance with a whole-of-government approach, which

refers to the executive. Recognition of health as a government priority is often crucial to an effective

implementation of HiAP.

On the other hand, in contrast to a whole-of-government focus, HiAP's reach into political decision-

making as part of the work of legislature implies that it can offer further mechanisms for

transparency and a health focus as part of a broader political process, including legislature

(parliament) and beyond, and, in particular, when approved as part of bi-partisan political

commitment and oversight, can establish broader accountability without being bound to policy

priorities or ownership of a particular government. While inclusion of legislature is likely to enhance

transparency, it is important for accountability that national policy processes ensure sufficient

transparency for HiAP in practice.

22HiAP has been used in the context of policies within United States

23See:http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf

Health in All Policies is an approach that systematically takes into account health and health

system implications of decisions across policy sectors at all levels to avoid harmful/adverse

impacts and seek synergies to improve population health, health equity and sustainability of

health systems.

It is founded on health-related rights and obligations and has its focus on public policies at all

levels of governance. At national level it applies to decision-making and processes both in public

administration and the executive (e.g. government) as well as in the legislature, with powers to

enact laws, control budget and decide upon taxes (e.g. parliament/congress/national assembly).
http://www.who.int/social_determinants/hiap_statement_who_sa_final.pdfhttp://www.who.int/social_determinants/hiap_statement_who_sa_final.pdfhttp://www.who.int/social_determinants/hiap_statement_who_sa_final.pdfhttp://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf


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2.2.2. Cooperation and joined up government policies

HiAPis likely to benefit from good practices in intersectoral co-operation and more joined up

government policies, but it can also be achieved without substantial or continuous horizontal co-

ordination or a joined up/whole-of-government basis for public management.24

While a focus on

good governance, joined-up government, policy coherence or co-ordination can provide essentialsupport to health in all policies, a stronger policy coherence may also undermine health if it is driven

by powerful sectoral or specific interests that negatively affect health, health protection, social and

environmental determinants of health, health system functioning and/or the financial sustainability

of health systems. A particularly contested issue is how commercialization of health care services

affects equity and financial sustainability of health systems. Governments will also need to maintain

policy space for health and regulation in the public interest as part of broader economic integration,

international services markets and agreements negotiated in the field of trade and investments25

.

HiAP is a means to place and maintain population health and health system needs higher up the

policy agenda and decision-making. However, it is necessary to be clear that it is not a means forhealth imperialism, but seeks to enhance more effective and enlightened policy making as well as

accountability for impacts from policy decisions across sectors. Policies which support social

protection, uphold human rights and support early child development can be essential for health

and in alignment with health policies, without necessarily flying a health policy flag. However, it is a

task for those seeking to enhance Health in All Policies to be able to analyse and understand how

other policies and decisions in other policy fields relate and influence health and health system

development.

HiAP is not a miracle pill against bad policies and does not guarantee that all government decisions

will prioritise health or implications to health systems, but it can be seen as a step further towardsbetter inclusion of health. As Health in All Policies is based on the broader context of governance, it

recognises that health may not be a key priority for all governments. Furthermore, HiAP does not

lead to diminishing responsibilities or obligations within the health sector for health systems,

population health and public health. It is essentially a means to address such health and health

system impacts and implications that are a consequence of policies and decision-making outside the

health sector.

2.2.3. Multisectoral action

Multisectoral action often implies that all sectors, including the private sector, are included in

planning and implementation of the programme, aim or action. It can be an effective means for

HiAP. In this respect a whole-of-society approach or multisectoral action can be seen as part of the

24The term whole-of-government has been used in public management as alternative to more narrow

approaches of new public management emphasizing horizontal collaboration and more unified response of

government work. It has also been used in combining development, defence and diplomacy in the so called 3d

approach. While implementing Health in All Policies can benefit from broader exercise of whole-of-

government approach, this is not a requirement for HiAP nor does it necessarily enhance health priorities. See

e.g.:Christensen T, Laegreid P (2007) The Whole-of-Government Approach to Public Sector Reform. Public

Administration Review 2007:1059-106.25

On globalization and policy space, see WHO Commission on social determinants of health paper: KoivusaloM, Labonte R, Schrecker T (2009) Globalization and policy space for health and social determinants of health.

Available from:http://www.globalhealthequity.ca/webfm_send/12
http://www.globalhealthequity.ca/webfm_send/12http://www.globalhealthequity.ca/webfm_send/12http://www.globalhealthequity.ca/webfm_send/12http://www.globalhealthequity.ca/webfm_send/12


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potential means and mechanisms for HiAP, much like committees or boards. Transparency and

participation are recognised as part of HiAP; however, this does not imply that the private sector,

stakeholders or nongovernmental organisations have equal powers with respect to public policy

decisions in the context of HiAP or that interest groups would need to be included in the planning,

development and implementation of all aspects of HiAP.

A focus on disparities and equity is an important part of HiAP and will also support action on the

social determinants of health. Understanding disparities and equity in the context of HiAP consists of

both relative and absolute differences. In other words, the concern is not only for impacts on the

most vulnerable groups, but also on differences across groups (i.e. gradient) or the scope for

governments to act on these. Furthermore, this entailsas part of addressing social determinants of

healththe distributional and redistributional impacts of changes that affect health system

financing and organisation. For example, pressures to impose or increase user charges in health care

can be imposed as result of priorities of other Ministries, yet it is known that user charges and

increased cost-sharing requirements by users have particularly negative implications to poorer and

less healthy population groups within societies. Similarly government policies defined in the context

of trade and innovation may result in substantially higher costs of medicines within health sector26

.

Finally, while Health in All Policies does reflect on health policies and while, for example, Health

Impact Assessments (HIA) are often used within health policies, HiAP is primarily an approach for

addressing other policies than health. However, it is also based on recognition that this role implies

that health sector also needs to engage with cross-sectoral requests and work from other sectors.

3. Achieving Health in all Policies

3.1. Prioritisation and focus

There are some key considerations that can help in taking up health in all policies more effectively.

These include prioritisation and strategic thinking: defining priority sectors and focus. Prioritisation

and strategic thinking on the key health and health policy concerns is of crucial importance in

directing limited resources and efforts. We need to understand not just the crucial health policy

issues, but also the scope for change through public policies, in other words how other policies and

policy decisions affect scope for change through public policies. It is useful to consider impacts both

in terms of population health and costs to the health sector, necessary regulation and regulatory

policy space for health and distributional implications, including impacts for social determinants ofhealth.

1. Definition of sectors and policies which matter for health, health system functioning, healthprotection, health promotion and key social determinants of health

26World Health Report in 2010, available from:http://www.who.int/whr/2010/en/index.html,

discusses challenges of health care financing and costs-sharing by users, on pharmaceutical policies, see for

example, Koivusalo M: Common health policy interests and the shaping of pharmaceutical

policies:http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8255209, or

Akaalephan et al. Extension of market exclusivity and its impact on the accessibility to essential medicines, anddrug expense in Thailand: Analysis of the effect of TRIPs-Plus proposal:

http://www.healthpolicyjrnl.com/article/PIIS0168851008002868/abstract
http://www.who.int/whr/2010/en/index.htmlhttp://www.who.int/whr/2010/en/index.htmlhttp://www.who.int/whr/2010/en/index.htmlhttp://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8255209http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8255209http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8255209http://www.healthpolicyjrnl.com/article/PIIS0168851008002868/abstracthttp://www.healthpolicyjrnl.com/article/PIIS0168851008002868/abstracthttp://www.healthpolicyjrnl.com/article/PIIS0168851008002868/abstracthttp://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8255209http://www.who.int/whr/2010/en/index.html


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a. Which policies in other sectors are relevant to the key health determinants in lightof current or emerging disease profiles within the country; which policies are

relevant to social determinants of health?

b. Which policies in other sectors are most relevant for health system organisationand functioning, health protection and standard-setting for health

28

?

3. Where timing can be strictly limiteda. On large planning and development projects that are carried further by the national

administration within a time-frame

b. Currently negotiated international agreements, partnerships or commitments madeas part of international cooperation, conferences or summits

4. Windows of opportunity for engagement29a. Renewal or other assessment of sectoral priorities or focusb. Change in policy relevance and/or civil society campaigning for changec. International processes or policy development in the field

3.2. Governance for Health in All Policies

Governance30

here describes how HiAPis addressed both within the public administration and as

part of a broader political process, including the legislature (parliament). The key requirement to

achieving a focus on Health in All Policies is sufficiently high-level executive (government) or broad

legislative (parliament31

) recognition of its importance. Political will is the inherent driver for policy

making and is important for initiating and moving forward on HiAP within a national administration.The inclusion of both executive and legislature is important for oversight and continuation of policies

from one government to another.

In practice substantial part of Health in All Policies will be implemented through national

administration or as result of decentralisation or devolution of powers, national and local

administrations. In many countries majority of decisions concerning health and public health are

made at sub-national level either in the context of federal states or regional and local governments

and administration. However, it is important that while powers for decisions concerning health may

have been decentralised, this may not be the case with respect to all decisions concerning other

policies. It is thus essential to focus on decision-making of legislature (parliament), executive(government) and national public administration (civil servants), at the level where decisions are

made.

28For example, in many countries substantial part of health protection and standard-setting measures are

done as part of environmental policies, transport or agricultural policies rather than as part of health policies

or within health sector. On the other hand, employment and environmental regulations affect also health

systems and their functioning.29

See e.g.http://sjp.sagepub.com/content/39/6_suppl/11.full.pdf+html30

For terminology on governance and related concepts, see e.g.

http://unpan1.un.org/intradoc/groups/public/documents/un/unpan022332.pdf31

the term Parliament is used here recognising that national parliamentary institutions may have distinctinstitutional features, names and working-methods. However, it is likely that a national adaptation or similar

mean or mechanism can be found.
http://sjp.sagepub.com/content/39/6_suppl/11.full.pdf+htmlhttp://sjp.sagepub.com/content/39/6_suppl/11.full.pdf+htmlhttp://sjp.sagepub.com/content/39/6_suppl/11.full.pdf+htmlhttp://unpan1.un.org/intradoc/groups/public/documents/un/unpan022332.pdfhttp://unpan1.un.org/intradoc/groups/public/documents/un/unpan022332.pdfhttp://unpan1.un.org/intradoc/groups/public/documents/un/unpan022332.pdfhttp://sjp.sagepub.com/content/39/6_suppl/11.full.pdf+html


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3.2.1. Legitimacy

Health in All Policies also draws legitimacy from human rights, civil, political, economic, and social

rights considerations for those governments that have either ratified international treaties or have

provisions within their own legislation. For example, the European Union is committed under the

Treaty of Lisbon to ensuring a high level of health protection in all policies. In Quebec, Canada,section 54 of the Public Health Act, adopted In June 2002

32, obliges government ministries and

agencies to ensure that the legislative provisions they adopt do not adversely affect the health of the

population, which has in practice resulted in an intragovernmental health impact assessment (HIA)

mechanism and the development and transfer of knowledge about healthy public policies.33

Legal

obligations provide continuity and cushion impacts from shifts in government policies or loss of

political interest in the area. Legislation on obligations with respect to assessing health implications

of all policies may not be able to guarantee that no negative implications take place, but will enable

governments to mitigate otherwise unanticipated impacts for health systems, population health or

the health of a particular sub-population from a policy or programme.

Legal obligations can also be crucial for calls to accountability or for civil society action, when the

health implications of other policies are deliberately not considered or omitted. This has been seen

as crucial, for example, in ensuring enforcement and implementation of environmental impact

assessments34

.Procedural justice has been a particular focus for environmental issues with a

substantial number of cross-sectoral aspects. The Arhus Convention in the environmental field

tackles in particular, access to information, participation in public policy making and access to justice

on environmental matters,35

aspects which have been echoed in the Rio Political Declaration on

social determinants of health. National human rights, public health and administrative law thus

provide in practice the hard framework for the promotion of Health in All Policies. While it is not

necessary for initiating a focus on HiAP, it can provide important support when there is no political

will or it is insufficient to take matters further.

3.2.2. Accountability

The WHO constitution emphasises government accountability in the constitution through the

statement that: Governments have a responsibility for the health of their peoples which can be

fulfilled only by the provision of adequate health and social measures36

. Accountability is crucial to

HiAP and thus needs to be understood as accountability of governments to their people. It is also

usually supportive to such performance accountability measurements, which value horizontal

collaboration, have greater risk tolerance and recognize that some problems require time to show

measurable results. Otherwise there is a risk that too tightly defined performance accountability can

limit the focus on cross-sectoral matters.

32See:http://www.ncchpp.ca/docs/Section54English042008.pdf

33See:http://www.ncchpp.ca/docs/Section54English042008.pdf

34See, e.g. Wathern P (1988, 2003; p.27)In Wathern P (ed) Environmental Impact Assessment Theory and

practice. Routledge London, New York.35

Arhus Declaration (1998). Available from:http://www.unece.org/fileadmin/DAM/env/pp/documents/cep43e.pdf36

WHO Constitution (1948). Available from:http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf
http://www.ncchpp.ca/docs/Section54English042008.pdfhttp://www.ncchpp.ca/docs/Section54English042008.pdfhttp://www.ncchpp.ca/docs/Section54English042008.pdfhttp://www.ncchpp.ca/docs/Section54English042008.pdfhttp://www.ncchpp.ca/docs/Section54English042008.pdfhttp://www.ncchpp.ca/docs/Section54English042008.pdfhttp://www.unece.org/fileadmin/DAM/env/pp/documents/cep43e.pdfhttp://www.unece.org/fileadmin/DAM/env/pp/documents/cep43e.pdfhttp://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdfhttp://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdfhttp://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdfhttp://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdfhttp://www.unece.org/fileadmin/DAM/env/pp/documents/cep43e.pdfhttp://www.ncchpp.ca/docs/Section54English042008.pdfhttp://www.ncchpp.ca/docs/Section54English042008.pdf


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HiAP supports in itself transparency37 as such as it makes governments more aware of the

implications of policy measures for other sectors, in relation to health, health policy priorities and

health systems development. This does not imply that health should be the highest priority for these

sectors, but that health and health policy implications gain due consideration as part of

policymaking, where other policies affect health, health systems, the scope for health policy

measures or social and environmental determinants of health. In terms of accountability, HiAP

benefits and requires public transparency for decision-process so that it is addressed appropriately

and not left merely as a rhetorical claim or another tick in the box measure with little relevance to

decision-making. Public transparency is important also for quality control in HiAP, with the possibility

to use health impact assessments or related measures to enable more participatory approaches.

3.2.3. Public participation

Public participation and participatory processes have become an important element for policy

making. This is the case also for HiAP, which benefits from dialogue and engagement with civil

society and usually requires this and transparency in order to thrive. While a Health in All Policiesapproach is essentially a means for public policymaking, governments and policymakers are free to

form structures or mechanisms that strengthen the role of civil society in health policy making as has

been done, for example, in the context of the establishment of the National Health Assembly in

Thailand.38

The benefits from public participation and participatory processes include wider consideration of

different aspects and strengthening of the democratic process, increasing empowerment and

control over decisions which impact on health as well as enabling articulation of issues and

considerations, which would otherwise be too difficult to address solely as part of government

policies. However, participation may also lead to overt influence of strong interest groups, result inimpaired engagement and capacities due to differential resources, enable corporate sector influence

to policy processes, can involve substantial conflicts of interests, and can be reactionary or used to

distract the policy process. Furthermore, governments will need to be clear between public

participation and processes of such private sector partnerships and stakeholder engagement

practices, which may imply further obligations and sharing of power39

.

3.2.4Co-benefits, mutual interests and conflicts of interests

Health in all policies across sectors is affected by the division of power within governments, which is

likely to be reflected in how different Ministries relate to health. Where powers and prestige across

Ministries is unequally balanced, political support is needed from a higher level than would

otherwise be the case. Furthermore, where Ministerial budgets are very limited it is necessary to

ensure sufficient resourcing for HiAP as well as to ensure that Ministries of Health have capacity and

ability to respond to the needs of other sectors for reciprocal engagement.

37Transparency of health implications of policy decisions addresses a different aspect than public transparency

of policy decisions as the latter applies in particular to access to information and availability of information

concerning policy decisions to the public. While the former is to enlighten policymakers, the latter has more to

do with means and mechanisms to enhance accountability of policymakers to the public.38

See, for example:http://en.nationalhealth.or.th/Health_Assembly39See for example: http://www.euro.who.int/__data/assets/pdf_file/0005/171707/Intersectoral-governance-

for-health-in-all-policies.pdf
http://en.nationalhealth.or.th/Health_Assemblyhttp://en.nationalhealth.or.th/Health_Assemblyhttp://en.nationalhealth.or.th/Health_Assemblyhttp://en.nationalhealth.or.th/Health_Assembly


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The initial starting point and impetus for Health in All Policies is often the co-benefits with policies in

other sectors. Co-benefit is a commonly used term in the environmental health and public health

field for describing the broader benefits of interventions, i.e. when action to reduce environmental

pollution also improves health and vice versa.

Mutual interests are often considered as equal to co-benefits, but in this framework the former are

used to indicate, in particular, political and collaborative interests, rather than policy impacts in the

given field or sector. While mutual interests are often driven by the presence of strong co-benefits,

they can also be driven by more policy-making related mutual interests with respect to, for example,

power or political party relations or the relevance of cross-sectoral practices for the sector as whole

(e.g. environmental policies vs. agricultural policies).

Win-win is a term used for either co-benefits or mutual interests and signifies a situation where both

sectors gain in one way or another. Win-Win situations are important for initiating action on HiAP

and for realising existing potential. However, while win-win prospects are important for initial

cooperation, the scope of HiAP should not be narrowed to win-win options alone, as greater health

policy concerns and challenges may remain within those sectors and policy issues, where there are

conflicting interests or a lack of co-benefits.

It is also possible that co-benefits and win-win potential is dependent on particular policy choices

within the other sector that may not have been recognised as a policy priority within the sector.

Health policy priorities may also be in conflict with one of the other sectors, but in line with priorities

of a third sector (e.g. environment). The challenge for HiAP is to recognise and understand where

there is scope for common interests and co-benefits and how different interests and co-benefits

relate in particular, where challenges are combined with substantial opportunities.

Strategic initial thinking may be necessary to focus on where key national health policy concerns are,

where potential longer-term priorities could be identified and what kind of a road map for HiAP can

be envisaged. This is also the context in which win-win options and co-benefits need to be

addressed. However, it is important that HiAP as a practice does not get blocked by requirements for

win-win solutions only as this would make it impossible to address policy decisions in areas where

there are conflicts of interests or a prospect for win-lose situation. It is likely that there are

divergences in the main interests across different sectors. In matters related to major conflicts of

interests, focusing on both the national administration and also policymakers in the national

parliament can be seen as mutually reinforcing (though separate elements in HiAP), as there are

limits to what can be achieved only through working within the national administration. This is due

to the fact that both within executive as well as in public administration, some sectors and policy-

makers may consider themselves as over and above others. This is a particular challenge in

addressing hard economic, trade and industrial policy issues or politically charged matters or

projects as then any engagement with HiAP may require stronger backing in the form of a formal

government policy stance, legal requirement or bi-partisan support in legislature (parliament) as well

as sufficient mechanisms for public transparency and accountability so as to provide sufficient

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4. Action for Health in All Policies

4.1. Public administration and executive

In the national public administration, different forms of intersectoral action have been the main

means of furthering HiAP, but Health in All Policies covers also government policies and decisions. As

result of decentralisation and devolution of powers it is crucial that as part of initial thinking on

Health in All Policies, the correct level for focus and action is explored so that focus on different

policy areas corresponds to the level of public administration, where key decisions and

implementation take place with respect to other policies at stake40

. However, this also implies that

while key health and health policy decisions may take place at the level of local or state

governments, key decisions in other policies of relevance to health can still be made at national or

even international level.

While HiAP has usually a strong intersectoral collaborative element, it does not necessitate

intersectoral action, particularly if:

i) other sector policies have no major relevance to health, health inequalities and equity,health systems or determinants

41of health, or

ii) there is nothing further to be considered from a health policy perspective beyondsupporting existing good policies.

4.2 Implementing HIAP within national public administration (executive)

In terms of the means to implement Health in All Policies, governments may consider utilising:

1. Intersectoral committees are a basic organisational structure for intersectoral action. These can

be formed as a) general committees within the administration for airing intersectoral issues as these

relate to health or b) with a more health-specific focus, such as nutrition, child health, or aging, or c)

as a specific and more multisectoral committee including representatives from nongovernmental

and private sectors. The health sector needs to be ready to d)engage with processes directed by

other sectors and e) to engage with broader-based intersectoral or multisectoral committee work

that is not directed on the basis of health needs. These can be important in opening up scope for

tackling health considerations when such a focus might not be achieved on the basis of health

considerations alone.

2. Health impact assessments can be required as part ofother impact assessments or on their own

for projects, programmes and policies. In some countries, an obligation to undertake a health impact

assessment is made as part of national legislation, whereas in others it remains voluntary or limited

to a project-level assessment or is required as part of an environmental impact assessment. The

strength of health impact assessments as a potential means for HiAP is the scope for requirement of

40As organisation of national administration and decentralisation of powers varies across countries, this

framework does not make explicit recommendations for national, state, regional and local level governments,

which will require adjustment to the governance structures within countries. In the context of EuropeanUnion, this would imply also recognition of the role of European Unionlevel policies in this context.41

Determinants of health would cover, in particular, social and environmental determinants of health


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HIA as a legal obligation as well as being a relatively developed practice at project level. On the other

hand it is not clear how well legal obligations have become realised and utilised in practice or how

HIA fits to analysis of impacts of different types of policies, integrated impact assessments or

implications to health systems.

While HIA has scope to be utilised as part of political decision-making processes it has so far been

used more as a technical device within administrations. Ample guidance on implementing health

impact assessments exists with experiences in particular in connection with environmental impact

assessments.42

When HIA is used as part HiAP, it may be useful to consider the following three issues:

1) How to address impacts on regulation and for policies, where impacts on health outcomes are in-

direct or apply to health systems or policy impacts, which are relevant but not easily quantified. The

traditional context of HIA practice is based on projects and health outcomes, which has both limits

and potential in the broader context of HIAP.

2) How to use of HIA for decision-making as part of the work of legislature. While HIAP extends to

legislature, the HIA practice is more focussed on use within administration.

3) How to address equity and impacts on social distribution of health as part of HIA. While HIA

practice is more established, focus on equity or social distribution of health remains still a challenge

in the context of HIA practice.

3. Policy reviews and assessments are often a less defined means for the purpose of assessing the

health or health policy implications of a particular policy. The focus, expertise and scope of these

assessments is often dependent on the length of time allowed in undertaking a policy review or

assessment as well as the focus and contents of the policy. The key to policy reviews andassessments is that these are done with sufficient understanding of health priorities and policy

needs so as to provide a health viewpoint or lens to the policy. This can be done within the health

sector or as part of a broader joint process as is recommended by the Australia Health Lens

Process,43

which can also be seen as a joint assessment and study.

4. Policy audits are usually used as means to assess policies and measures and whether already

existing legislation has been followed. A traditional context of audits is the focus on financial

statements and economic performance and implementation of policies. Audits are easier to

undertake when there are legal requirements or explicit policies with targets. A policy audit that is

done wisely can give further scope for Health in All Policies in terms assessing the current state ofart, but in practice audits may be more helpful in monitoring, assessing and evaluating what has

been done. Audits have been made, for example, on how health and safety regulations have been

followed, but a potential focus for HiAP interests is the practice of health equity audits in the United

Kingdom44

42See more, for example on:http://www.who.int/hia/en/

43See more on:

http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/health+

in+all+policies/health+lens+analysis44See, on health equity audits:http://www.nice.org.uk/niceMedia/documents/equityauditfinal.pdf, and for

health and safety audits, for example,
http://www.who.int/hia/en/http://www.who.int/hia/en/http://www.who.int/hia/en/http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/health+in+all+policies/health+lens+analysishttp://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/health+in+all+policies/health+lens+analysishttp://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/health+in+all+policies/health+lens+analysishttp://www.nice.org.uk/niceMedia/documents/equityauditfinal.pdfhttp://www.nice.org.uk/niceMedia/documents/equityauditfinal.pdfhttp://www.nice.org.uk/niceMedia/documents/equityauditfinal.pdfhttp://www.nice.org.uk/niceMedia/documents/equityauditfinal.pdfhttp://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/health+in+all+policies/health+lens+analysishttp://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+reform/health+in+all+policies/health+lens+analysishttp://www.who.int/hia/en/


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5. Joint action and common projects across different ministries and departments can be used to

further health considerations where more focus is of importance. They are likely to be most

effective where there are clear co-benefits or mutual interests in joint work, while they can cover

either broader areas or more specific issues of concern. This type of project can go deeper into the

issues as well as provide crucial political support across sectors on matters that are complex or

require broader action across different sectors (e.g. air pollution).

6. The practice of routine regulatory reviews and assessments is often used to ensure that legal

changes proposed for one policy area or sector are not in conflict with those proposed for another.

These can be useful in making more coherent policies within government as well as in identifying

potential problem areas, but can become burdened by power-relations or cross-trading of

acceptability across Ministries, sectors and departments. In Finland, for example, these reviews or

assessments of proposed legislation are public documents, which may not necessarily be put on the

web, but can be inquired by the public.

7. Open consultations and transparency of decision-making and consultation practices. Rio Political

Declaration explicitly pledges to:

Promote and enhance inclusive and transparent decision-making, implementation and

accountability for health and health governance at all levels, including through enhancing access to

information, access to justice and public participation;

Consultation can be done first at intersectoral level and then with the broader public and interest

groups. Internet and web-based consultations are easy to initiate, but it is necessary to recognise the

relevance of the digital divide and different capacities across different stakeholders. Public interests

and general interest matters may gain less attention in comparison to specific and economicinterests. Furthermore, web-based consultations are not without expenses as these require time for

planning and garnering responses. When participation in web-based or electronic consultation is

active, it can lead to a substantial number of submissions, requiring adequate capacities to address,

respond and deal with these in a transparent manner.

8. Special envoys, special rapporteurs, commissioners, offices and ombudsperson/men45

can

highlight broader HiAP priorities or more specific health-related concerns through a more specific

focus effectively. While special envoys and offices tend to have proactive roles in promoting a

particular matter further usually on the basis of related expertise focus, the role of commissioners

and rapporteurs can be more mixed or remain more in securing focus and action for commitmentsmade. Special envoys or commissioners are also used for more public relations agenda so as to

benefit from earlier work or celebrity status of the persons without necessary experience or

particular expertise or engagement in the related area. The role and relevance of this type of

positions is likely to depend strongly upon number of persons appointed as well as their personal

capacities and integrity with respect to issue in question.

on:http://www.ukfsc.co.uk/files/SMS%20Material/Examples%20of%20Forms/Sample%20AUDIT%20CHECKLIS

TS.pdf45

There are different ways to define the given positions not only across countries, but also disciplinary fields

and area of focus, however, the role of ombudsmen is more defined. According to Oxford English Dictionaryombudsman is: an official appointed to investigate individuals' complaints against a company or organization,

especially a public authority.
http://www.ukfsc.co.uk/files/SMS%20Material/Examples%20of%20Forms/Sample%20AUDIT%20CHECKLISTS.pdfhttp://www.ukfsc.co.uk/files/SMS%20Material/Examples%20of%20Forms/Sample%20AUDIT%20CHECKLISTS.pdfhttp://www.ukfsc.co.uk/files/SMS%20Material/Examples%20of%20Forms/Sample%20AUDIT%20CHECKLISTS.pdfhttp://www.ukfsc.co.uk/files/SMS%20Material/Examples%20of%20Forms/Sample%20AUDIT%20CHECKLISTS.pdfhttp://www.ukfsc.co.uk/files/SMS%20Material/Examples%20of%20Forms/Sample%20AUDIT%20CHECKLISTS.pdfhttp://www.ukfsc.co.uk/files/SMS%20Material/Examples%20of%20Forms/Sample%20AUDIT%20CHECKLISTS.pdf


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A good example of using this type of more specific focus is the emerging number of independent

human rights institutions for children often represented in the form of childrens commissioners and

ombudsmen, which have followed the negotiation of the Convention on the Rights of the Child and

become emphasised as a key to implementation of the Convention46

. Another example in the field

of human rights is the establishment of the position of a special rapporteur on Right to Health47

Ombudspersons/men have usually a more defined position based on their role to respond to

complaints in a defined area or organisation. The role of an ombudsperson/man can be based on

internal, external (citizen) or both sources of complaints. Specific ombudspersons/men for children

were first initiated in Norway, in 1981 and followed by Costa Rica in 1987, with currently already 33

countries in the European network of ombudspersons/men for children48

.

9. Issue-based multisectoral action. While issue-based committees can include multisectoral actors,

one step further towards engagement or perhaps whole-of-society types of policies is that of

multisectoral collaborative action and networking. It can take place through different forms of joint

efforts, networks and partnerships across several sectors and actors. This type of focus and action

can be very effective, but can often be done only for a limited number of issues and can be difficult

to manage and sustain due to the larger number of actors. As it can include partners with a variety

of interests, it is different from joint action and common projects across sectors.

There is currently substantial scope for enhancing focus on multisectoral action in the context of

non-communicable diseases as result of the Political Declaration on NCDs in 2011, in particular in

Article 54, which commits signatories to: Engage non-health actors and key stakeholders, where

appropriate, including the private sector and civil society, in collaborative partnerships to promote

health and to reduce non-communicable disease risk factors, including through building community

capacity in promoting healthy diets and lifestyles;

WHO has already provided guidance on lessons learned from multisectoral partnerships as well as

provided further guidance on the matter49

. While partnerships can focus on noncommunicable

diseases as such, they can also engage with particular social or environmental determinants or

conditions (e.g. obesity or malnutrition) or requirements (e.g. nutrition).

4.3. HiAP in the legislature and decision-making process

The focus of traditional intersectoral action or the more recent emphasis on cooperation and joint

governance have all predominant focus on public administration, how new programmes aredeveloped and how civil servants work. While Health in All Policies seeks to contribute to this

process it is a means to reach into political decision-making processes and practices in the

legislature: in other words, to create political accountability for health. In addition to civil servants

and public sector contractors, also politicians themselves are key players in HiAP and how it is used

46See, for example: http://www.unicef-irc.org/research/208/

47See, for example the interview of first special rapporteur: http://projects.essex.ac.uk/ehrr/V2N1/Hunt.pdf

48On Ombudspersons/men, see Reif, LC. The Ombudsman, Good Governance and the International Human

Rights System, Brill Academic Publishers, 2004. For European network of ombudspersons for children

see:http://www.crin.org/enoc/, for UNICEF study on independent human rights institutions for Children, see:http://www.crin.org/enoc/49

See e.g. :http://www.who.int/nmh/events/2012/consultation_march_2012/en/index.html
http://www.crin.org/enoc/http://www.crin.org/enoc/http://www.crin.org/enoc/http://www.crin.org/enoc/http://www.crin.org/enoc/http://www.who.int/nmh/events/2012/consultation_march_2012/en/index.htmlhttp://www.who.int/nmh/events/2012/consultation_march_2012/en/index.htmlhttp://www.who.int/nmh/events/2012/consultation_march_2012/en/index.htmlhttp://www.who.int/nmh/events/2012/consultation_march_2012/en/index.htmlhttp://www.crin.org/enoc/http://www.crin.org/enoc/


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as part of their work as decision-makers in the legislature (parliament). Recognition of HiAP as part

of government priorities is important in giving legitimacy totaking the approach further and as part

of its operationalization. The key means for giving political support to HiAP within government

include a) explicit recognition and endorsement in a government programme, b) allocation of

specific Ministerial responsibilities for HiAP and c) establishing specific measures/plans of action or

programmes in support of HiAP. Further legitimacy can be gained from broader bi-partisan (cross-

party) parliamentary support or a statement that broadens the ownership of HiAP and limits the

vulnerability of being linked to specific regimes or parties in power.

Integration of HiAP as part of the political process is of more importance when political will is

inconsistent, lacking or is not wholly supportive towards health priorities within government, or if

the practices of the civil service are slow to change. It can also be essential in creating space to work

with reluctant and/or more powerful sectors. However, HiAP cannot guarantee that health is at

the core of the concerns for all policy-decisions, but rather that it is taken up and discussed as part

of decision-making and that decision-makers understand better and are aware of potential or

expected health and health policy implications of the decisions made. Potential means for processes

involving the legislature50

include the following:

1. Specific committees. In many Assemblies and Parliaments there are specific committees for

health that can provide oversight and scrutiny of the policies made in other sectors. A decision can

be made that particular policy areas are always subject to the scrutiny of the health committee.

Alternatively it is possible to have a review committee for one sector or jointly with other sectors

(e.g. health, environment, sustainability, inequalities)

2. Required review and oversight processes. Health can be included as part of required impact

assessments. Environmental and sustainability review boards and committees have been used to

provide broader oversight of policies in other sectors as a whole. One example of such a committee

is the environmental audit committee in the United Kingdom, whose remit cuts across government

rather than focusing on the work of a particular department.51

The relevance of this type of focus is conditioned on scope for change in the process of governance

as if this type of measure is done in very late stage of the decision-making process, this type of

oversight can become redundant or even corrosive if it forces to procedural acceptance irrespective

of actual implications.

3. Hearings and consultations. Hearings and consultations usually take place on the basis of aninvitation of experts in the field as well as canvassing the views of various stakeholders and interest

groups. Hearings, consultations and debates provide scope for taking in broader views on health-

related matters as part of decision-making. For example, in the United States congressional hearings

are key methods by which committees collect and analyse information for policy-making. The

50Legislature is according to Oxford English dictionary the legislative body of a country or state. Depending of

the country it can be referred, for example, as a parliament, house of representatives, congress or assembly

for national or state governance. At local level a similar body could be, for example, municipal council. In

addition, there are regional parliamentary assemblies which can be formed by union of national assemblies oras separate institutions, such as European Parliament.51

See, for example:http://www.parliament.uk/eacom/
http://www.parliament.uk/eacom/http://www.parliament.uk/eacom/http://www.parliament.uk/eacom/http://www.parliament.uk/eacom/


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Ministry of Health can also support NGO access and capacities to articulate health-related issues as

part of other policy developments.

4. Parliamentary coalitions, networks and multistakeholder groups. In many parliaments there are

cross-party coalitions and networks with particular aims or priorities. It may be useful to consider

the extent to which this type of coalitions can be useful in taking health in all policies further in

general or focus on a particular issue. Issue-based groups can also be important in enabling bi-

partisan support for a specific cause or policy issue. The Ministry of Health can facilitate and support

this kind of engagement directly or through collaboration with NGOs by providing a secretariat for

this type of activity. In the European Parliament, intergroups are, for example, organised through

this type of action and can be facilitated by nongovernmental organisations.52

5. Public Health Reports. Public Health reports with a focus on public health concerns and policies in

other sectors or more specific reports by different sectors can be used to draw attention to health-

related matters or as a basis for scrutiny or parliamentary hearing. . While reports can still convey

important information and material for follow up, their relevance to policy-makers can not be taken

granted if reports become a routine process or if they are not discussed in parliament. In this

respect, reporting can benefit from: i)a balance between comprehensiveness and reporting interval,

ii) a changed focus or overarching theme for each report, iii) a proper expert evidence or hearing in

parliament associated with the output of the report53

. In addition to specific public health reports,

other options can include adding a health focus to reporting made for other policies or more specific

concerns. Reporting can also be used to support and enhance accountability through the

requirement of reporting on how health has been considered as part of planning and policy-making

or in terms of implications of particular policies to social distribution of health.

6. Issue-based collaborative action. Political alliances and action are made of common causes and

priorities, where a crucial or broader health-determinant-related focus (e.g. food security,

sanitation, poverty) can provide a useful basis for collaboration and change across different parties

more effectively than a focus on health as such. For example, addressing broader focus on poverty,

housing and sanitation can be crucial to health, without the need of this being discussed explicitly as

a health matter or under a health-related leadership and activity. However, support from health

sector can be crucial for initiating collaboration or policy action. In order to enable issue-based

collaborative action, where focus is not on a health issue lead by another sector, it may be necessary

to be explicit that Health in All Policies can also include support and participation to collaborative

activities in other sectors.

4.4. Civil society and private sector

1. Broader participation and scrutiny regarding health allows scope for bringing up new discussions

and exchanging with broader civil society and different interest groups. Although these can be open

to citizens, the representatives of civil society often include as main actors public interest

organisations, specific interest groups and the research community. Consultations may in this

context need careful planning so as to ensure transparency and broad participation on the one hand,

52

See:http://www.europarl.europa.eu/aboutparliament/en/00c9d93c87/Intergroups.html53On Public Health Reporting

see:http://ec.europa.eu/health/ph_information/documents/health_in_all_policies.pdf
http://www.europarl.europa.eu/aboutparliament/en/00c9d93c87/Intergroups.htmlhttp://www.europarl.europa.eu/aboutparliament/en/00c9d93c87/Intergroups.htmlhttp://www.europarl.europa.eu/aboutparliament/en/00c9d93c87/Intergroups.htmlhttp://ec.europa.eu/health/ph_information/documents/health_in_all_policies.pdfhttp://ec.europa.eu/health/ph_information/documents/health_in_all_policies.pdfhttp://ec.europa.eu/health/ph_information/documents/health_in_all_policies.pdfhttp://ec.europa.eu/health/ph_information/documents/health_in_all_policies.pdfhttp://www.europarl.europa.eu/aboutparliament/en/00c9d93c87/Intergroups.html


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but on the other avoid dominance and distraction by interest groups and stakeholders with a strong

conflict of interest, while ensuring that representatives from research community and public interest

organisations are heard sufficiently.

Private sector is generally considered part of civil society and thus part of public participation

process. Where there are strong conflicts of interests, these need to be recognised and addressed.

The guiding power of participatory processes do also have limits as those who participate have often

different levels of capacities, resources and scope for lobbying and enhancing a particular view or

interest. There may be differential access to policy processes between groups, often favouring larger

and stronger interest groups. Where commercial interests are of major importance, these may also

be represented through funding of other civil society groups and more specific astro-turf groups,

often established for the purpose of lobbying.

Participatory and scrutiny processes can include inviting civil society and research community

representatives to give evidence or take part in broader hearings, seminars or consultations, with a

more open floor and larger numbers of participants. Transparency is important for participatory

processes as well as clarity and openness with respect to conflicts of interests. New information

technologies allow for broader participatory processes and scrutiny, however they can result in

substantial number of replies requiring adequate allocation of working-time for handling responses.

It is also important that participatory processes have sufficient transparency with respect to where

and how particular views and suggestions have come from as otherwise it can become a

smokescreen for cherry picking particular views as if these would have been formed by consensus.

2. Deliberative methods and mechanisms to better include and address the views of citizens.

While it is necessary to recognise the broader political context of participatory processes, this shouldnot be seen as a judgment against efforts to engage with deliberative processes and efforts to

include and address the views of citizens. This is important not only for policy issues, but as well for

the implementation of Health in All Policies approach as such.

A particular policy innovation and development in the area has been the establishment of the

National Health Assembly in Thailand, which has been found successful in bringing together various

actors and sectors involved with health. It is a particular effort of more participatory policy-making in

comparison to more traditional focus on expert or stakeholder focus. While efforts build on national

practices, experiences and expertise, this model entails substantial potential for different countries.

In terms of future role and relevance of National Health Assemblies, three challenges have beenidentified in terms of i) whither the representation of groups and networks who attend adequately

reflect the real health needs of the country?, ii) How does the National Health Assembly ensure the

implementation of its resolutions?, and iii) How to develop networks and build capacity in the health

assembly process, especially in the process of developing recommendations, considering resolutions

and advocating their implementation?54

Another potential mechanism is the use of citizens' juries, where citizens selected from the

population can sit in the form of a jury and can cross-question expert witnesses before collectively

54Read more from the source

:http://www.who.int/sdhconference/resources/rasanathan_healthexpectations.pdf
http://www.who.int/sdhconference/resources/rasanathan_healthexpectations.pdfhttp://www.who.int/sdhconference/resources/rasanathan_healthexpectations.pdfhttp://www.who.int/sdhconference/resources/rasanathan_healthexpectations.pdfhttp://www.who.int/sdhconference/resources/rasanathan_healthexpectations.pdf


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producing a report to an oversight panel that can include policy makers and other interest parties,

who then decide how to respond. They have been used in the United States55

and Great Britain56

as

well as part of development policies and efforts to improve understanding of the views of vulnerable

or hard to reach groups.

Alternative mechanisms to draw views from the general public or particular population groups are

opinion surveys, focus groups and different types of e-cafes, knowledge cafes, open spaces and

website commentaries. These types of mechanisms can be useful for complex cross-sectoral issues

and may help in understanding the extent of support of the ordinary public57

in contrast to the views

of specific interest groups or lobbyists, which often can engage more effectively in consultations and

policy-making process. However, it can still be difficult to assess to what extent the presented views

in the consultation process are representative and how questions and forms of participation can

affect the results58

.

3. Budgetary review and discussion is crucial for different policy areas as well as to the allocation of

resources. While policies can take different forms and priorities, it is the budget that often defines

what is realised. Providing scope, monitoring or assessment of the budget from a health policy

perspective can provide a means for realising Health in All Policies in practice. Budgetary review has

been in some countries an important part of civil society action, although it has a tendency to focus

more on the allocation of resources in support of specific programmes or services within the health

sector. This kind of review has been sought also in other sectors, for example, in relation to action

on climate change,59

and gender budgeting.60

Gender responsive budgeting has been implemented in

a number of countries with variety of experiences, including in low and middle-income countries,

such as India and South-Africa.61

In the United Nations UNIFEM has provided guidance on gender

responsive budgeting62

. A particular area for focus in development policies has been pro-poor

budgeting63

. Pro-poor budgeting experiences have been introduced as part of development policies

with focus on health and education services, but not necessarily on broader determinants of

health64

. While budgeting approaches are likely to face political struggles, national policy space for

55See, for example,http://www.jefferson-center.org/index.asp?Type=B_BASIC&SEC={2BD10C3C-90AF-438C-

B04F-88682B6393BE}56

See, for example,http://www.peopleandparticipation.net/display/Methods/Citizens+Jury 57

The purpose is to have a random sample of views or gather views from hard to reach groups, however as

numbers of those consulted remain small, there can still remain substantial margin of error. Websites views

can also represent a more selected group of people than it may be anticipated.58The people who use their time to participate in consultation processes may not be the same as those not

doing so or declining from the opportunity. It is known that questions and format of interviews or

questionnaires can substantially influence answers.59

See, for example:http://www.ieep.eu/work-areas/governance/eu-budget/60

See, for example:

htt

HIAP Framework_version 2

Documents

Transcript of HIAP Framework_version 2