Some weeks ago, WHO convened its eighth Global Conference on Health Promotion in Helsinki together with the Ministry of Social Affairs and Health of Finland. The conference focus was on how to promote health and equity by implementing a Health-in-All Policies (HiAP) approach, centered around the ‘how’ rather than the ‘what’ by discussing and sharing best practices among the nearly one thousand participants gathered from around the world. The five-day conference thus offered a window of opportunity for policymakers to discuss lessons learnt and provided some interesting insights in the field of HiAP implementation.
Using a HiAP approach means ensuring that health considerations play a role in all public policy decisions and clearly work best when the parties or sectors involved have mutual interests or co-benefits, for example by seeking synergies between health and education or health and environmental goals. Tools for implementing HiAP are available, including health impact assessments, regulatory measures, and fiscal measures, as well as new methods for measuring equity. Presentations highlighted the importance of central leadership (heads of government are best placed to lead the HiAP approach), regulation, and a workforce capable of negotiating complexity, facilitate social change, and create conditions that promote favorable political decisions.
The rather flawed Helsinki Statement, however, was criticized by civil society and superseded by a call to action issued by the People’s Health Movement, which attribute the widening inequalities in income and wealth within and between countries and the resultant health inequities to an unfair economic system with ‘complex roots in the dominant global capitalist regime… and undemocratic governance at national and international levels.’ Activists hence called for the establishment of HiAP as a high priority within WHO to enable work in areas with conflicting interests and priorities, to democratize the governance of global bodies such as the UN and the World Bank (WB), and to increase regulation of the financial sector, amongst others.
The issue of corporate power was also raised in a heated debate on the role of the private sector, including a WB talk about its new corporate commitment to eliminate poverty and the boosting of shared prosperity, and private sector tools and challenges for sustaining the post-2015 agenda. Although the speeches led some to believe the public was treated to what was dubbed a corporate ‘health wash’ and dissenting voices where screened on the massive message wall on-stage and heard through public interventions, there was room for interpretation. Innovative approaches can indeed be learnt from the private sector and the new policy course of the World Bank, as indicated by Jim Kim’s speech at the last WHA, has raised some expectations.
The HiAP approach is, however, most of all dependent on strong (political) leadership, as exemplified by the pioneering role Finland has played in introducing the concept into regional decision-making under the Finnish EU presidency in 2006. This has directly informed the new health policy framework for Europe, Health 2020, which has been described as a 21st century governance for health. This innovative ‘whole-of-government’ and ‘whole-of-society’ approach for health is firmly grounded in the values of human rights and equity, achieving global and societal goals through new interconnected forms of governance, in turn creating new partnerships and backed by the strong voice and involvement of civil society.
As stated by the Regional Director of WHO Europe, Zsuzsanna Jakab, in her keynote intervention at a special Europe Day devoted to showcase inspirational achievements related to implementing HiAP approaches in the EU, the new framework offers a values- and evidence-based policy within which HiAP can be implemented. For example, HiAP is considered an essential pillar in the Action Plan on NCDs for 2012-2016, given that the wider determinants of the NCD epidemic lie largely outside the control of the health sector and there is clear evidence of the cost-effectiveness of HiAP, for example through the use of fiscal policies to control harmful alcohol use and social welfare spending.
The globalization of unhealthy lifestyles moreover requires multisectoral and multi-stakeholder engagement to address NCDs as a global development challenge. A UNDP desk review, however, indicated that national action plans for addressing NCDs frequently cite multisectoral links, but that frameworks for integration are still lacking and public misconceptions about NCDs are rife. M&E frameworks are required but absent beyond the health sector, and funding still favours communicable diseases in countries suffering from both. Regional differences also indicate that attention to NCDs remains weak in sub-Saharan Africa, and an overall UN Task Force has been established to support the global NCD agenda.
Tobacco control clearly remains the exception, with most countries implementing a comprehensive national strategy based on the WHO Framework Convention on Tobacco Control (FCTC), which is also recommended as a framework for the use of legal tools to implement HiAP. However, as WHO Director-General Dr Margaret Chan stated in her remarkable opening address, ‘it is not just Big Tobacco anymore – public health must also contend with Big Food, Big Soda, and Big Alcohol,’ and ‘all these industries fear regulation and protect themselves by using the same tactics, including front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt…’
These global corporate strategies also increasingly extend to LMICs, where for example tobacco creates an additional burden for the health and well-being of low-income populations but capacity is weak to counteract industry strategies and products. The power of international trading mechanisms may also severely hamper public health benefits, as illustrated in Helsinki by a case study presented by the Samoan Minister of Health. Samoa introduced a ban on the import of high-fat turkey tails in 2007 amidst concerns about the high rates of diabetes, obesity and heart disease, but was later forced to lift the ban during its bidding process to join the World Trade Organisation – clearly indicating the need to use HiAP approaches at global level.
HiAP have so far been largely confined to national or regional levels in higher-income countries, but some lessons can also be learnt from middle-income countries. A popular example is the implementation of social protection policy in Brazil, which has clearly shown the impact of its conditional cash transfer programme on childhood mortality. Other examples include the development of a comprehensive intersectoral program to improve population health through a Healthy Cities approach in Changchun, China, or the institutionalization of Health Impact Assessments (HIA) in Thailand. Maybe the most impressive example, however, was the HiAP approach adopted by the Ministry of Social Development of Ecuador and the role of the Ministry of Health in collaborating and engaging with other ministries and agencies for health in Tunisia following the Arab spring.
The role of the health sector in implementing HiAP could clearly be one of stewardship and facilitation of the process in other policy sectors, as the fight against communicable diseases such as SARS and health equity integration may indicate. Drawing upon lessons from all around the world a strong case can thus be made for HiAP, which in Helsinki was endorsed not only by the Conference Statement and publication of a book: ‘HiAP: Seizing opportunities, implementing policies,’ but also by the discussion of a Framework for Country Action, aimed at giving countries concrete guidance on how to implement HiAP in their respective regions. Whether this goal will be achieved in due time, however, remains to be seen, bearing in mind that HiAP is but one of the original action areas of health promotion. Or, as a keynote speaker pointed out: ‘Health promotion is our dream; HiAP is the plan.’