Public Health Health in All Policies in European Countries
by
Tapani Melkas, Marita Sihto
  • LAST MODIFIED: 27 April 2017
  • DOI: 10.1093/obo/9780199756797-0163

Introduction

Health in All Policies (HiAP) can be summarized as systematic, integrated work for health in all policy sectors. Population health is influenced by a multitude of factors, from individual biological factors to structures of society. Many of these factors, or health determinants, can be influenced through policies in various arenas of policymaking. The terminology, from intersectoral action for health to healthy public policy and HiAP, can be seen as a continuum with increasing integration and strengthening of the role of whole-of-government. There are, however, a variety of definitions and interpretations in the literature. A majority of the literature examines the issue from the health sector perspective, while the perspective of broader government is lacking. The impact of material and social conditions on health has been understood for centuries. The development of scientific medicine in 19th and 20th centuries led to an increasing influence of health care and to a general thinking that the health-care system is the policy instrument for health. Rising expenditures and slow or missing progress in complex problems such as health inequity, noncommunicable diseases and problems of aging, led to the realization that opportunities of many sectors were not fully utilized. The World Health Organization (WHO) emphasized intersectoral collaboration in Health for All program from the 1970s, and many European countries followed the program’s spirit. The term HiAP comes from the health theme of the Finnish 2006 presidency of the European Union (EU). Following some backward steps in national public health as a result of EU policies, Finland wanted to emphasize the responsibility of health protection in all EU policies, as was stipulated in the EU Treaty. The approach has been developed further and implemented, particularly in western Europe, North America, and Australia, and increasingly in developing countries, for example in Latin America, and by the WHO. A majority of European countries are EU members or associated countries and have delegated a large share of their competence in most policy sectors to the EU. Consequently, decisions having an impact on health are largely made at the EU level, leading to a need for supranational HiAP. This is not much reflected in the literature, where national and local policy studies dominate. Social determinants and inequity in health have gained increasing attention. The ongoing strategy of the WHO European Office (WHO/EURO), Health 2020, aims to decrease inequity by utilizing HiAP. Good results in the work of non-health sectors have been demonstrated, for example in traffic safety and social protection. Evidence on achieving equity targets is, however, missing, though expectations are high. Despite much rhetoric, the political struggle concerning the division of resources in society has rarely led to a real mitigation of the unequal pattern of health determinants. Successful implementation of HiAP needs a legislative basis, governance and leadership, structures for cooperation, feasible tools, and competent capacity. Literature on these is presented here with the aim of addressing the social, economic, cultural, and political variation among countries in Europe, leading to varying solutions.

General Overviews

In this section we have collected a few works that will help one become acquainted with the topic. Wismar and Martin-Moreno 2014, in the textbook Facets of Public Health in Europe, though short, is a very informative, compact, and systematic account of HiAP. It can be used by those studying public health, but also by experts working in administration sectors with relevance to health. Ollila 2011 is another short report describing the history, strategies, tactics, and tools of HiAP, mainly on a national level but not forgetting the supranational level. Ollila concludes that the health sector remains the key actor and that experts in public health should identify and prioritize the population’s needs, analyze policies, and suggest feasible solutions. Larger overviews are available to those more interested. The edited book Leppo, et al. 2013 is presented here as an example of an up-to-date comprehensive book. It was prepared for the eighth WHO World Conference on Health Promotion and thus has global perspective, but since many of the contributors are Europeans the book has high relevance to European health policy. Kickbusch and Buckett 2010 is a book prepared for the International Meeting on HiAP in Adelaide. The main focus of the book is on South Australian experiences, but there are also general parts, including a compact article on HiAP in Europe by Wismar and Ernst. The book consolidates key issues of HiAP and enlarges perspectives for those working with European health policy. Ståhl, et al. 2006 highlights why and how health should be taken into account in EU and national policies in all sectors. The scope is European—it is based on European values, and it emphasizes the unique competence and obligation of the EU in protecting health. Two WHO documents present the organization’s and active participants’ views on HiAP. The Helsinki Statement on Health in All Policies 2014 is the joint understanding of politicians, international experts, nongovernmental organizations (NGOs), and other participants of the world conference on priorities in advancing HiAP. Health and equity are regarded as a core responsibility of government, but the leadership is left to health ministers. World Health Organization 2015 is the response to the world conference accepted in the World Health Assembly. It provides guidance to member states on taking country-level action across sectors. The report emphasizes that government as a whole bears the ultimate responsibility for the health of citizens, with the health sector having a strong advocacy function for all sectors.

  • The Helsinki Statement on Health in All Policies. 2014. Health Promotion International 29 (Suppl. 1): i17–i18.

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    The statement presenting the basic outcomes of the eighth Global Conference on Health Promotion in 2013, including appeals to governments to adopt HiAP and to WHO to support member states and the use of the HiAP approach in working with other international organizations and agencies. Statement is available online from the WHO.

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    • Kickbusch, I., and K. Buckett, eds. 2010. Implementing Health in All Policies: Adelaide 2010. Adelaide: Department of Health, Government of South Australia.

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      The book has four sections. The first concerns the evolution and fundamental characteristics of HiAP; the second examines international perspectives, including Europe; the third deals with theoretical and methodological perspectives; and the fourth presents health lens analysis as a tool facilitating HiAP implementation. The book utilizes South Australian experiences.

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      • Leppo, K., E. Ollila, S. Pena, M. Wismar, and S. Cook, eds. 2013. Health in All Policies: Seizing opportunities, implementing policies. Helsinki: Ministry of Social Affairs and Health.

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        A book on HiAP by high-level experts, containing a general overview of the contents and development of HiAP; analyses of eight policy areas; and lessons for the health sector, politicians, policymakers, researches, and civil society advocates. The perspective is global, but the book discusses a lot of European experiences and is useful for anybody interested in HiAP.

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        • Ollila, E. 2011. Health in All Policies: From rhetoric to action. Scandinavian Journal of Public Health 39:11–18.

          DOI: 10.1177/1403494810379895Save Citation »Export Citation »E-mail Citation »

          An article examining the opportunities and challenges for strengthening the HiAP approach, utilizing experiences from Finland and the European Union. Four strategies characterizing HiAP are outlined. A main role is suggested for experts in public health, who should analyze health implications of policies, making them understood by policymakers, as well as suggest feasible solutions.

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          • Ståhl, T., M. Wismar, E. Ollila, E. Lahtinen, and K. Leppo, eds. 2006. Health in All Policies: Prospects and potentials. Helsinki: Ministry of Social Affairs and Health.

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            A review of multisectoral health policy in the European Union and its member states. The articles cover the main aspects of HiAP, sectorial experiences, governance, and tools. The book was published for the Finnish EU presidency and all the writers are Europeans.

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            • Wismar, M., and J. Martin-Moreno. 2014. Intersectoral working and Health in All Policies. In Facets of public health in Europe. Edited by Bernd Rechel and Martin McKee, 199–216. European Observatory on Health Systems and Policies Series. Milton Keynes, UK: Open Univ. Press.

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              A short overview of HiAP in today’s Europe that emphasizes intersectoral governance and has a practical orientation. The work of WHO/EURO and the EU are well presented. A feasible first step for becoming acquainted with the subject.

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              • World Health Organization. 18 May 2015. Draft framework for country action across sectors for health and health equity. 68th World Health Assembly A68/17, Provisional agenda item 14.5. Geneva, Switzerland: WHO.

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                WHO’s up-to-date understanding on HiAP implementation. Guidance for countries consists of six components: needs and priorities; supportive structures and processes; framing the planned action; facilitating assessment and engagement; establishment of a monitoring, evaluation, and reporting mechanism; and capacity building. Necessary for all building national policy.

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                WHO/EURO and Regional Frameworks for National Action

                WHO/EURO has developed and advocated multisectoral health policy to support the member states in the Health for All program in Europe, where many countries have faced major upheavals in the past decades. Improved population health and equity in health were the goals to be achieved by influencing determinants of health. The first important milestone was a report on targets, WHO Regional Office for Europe 1985. Targets, connected problems, and suggested solutions were to facilitate countries in formulating their national policies. WHO/EURO adopted HiAP soon after its launching as a consequent continuation of its earlier work on intersectoral collaboration and healthy public policy. There have been comprehensive programs, the latest being Health 2020 (WHO Regional Office for Europe 2013). The program emphasizes the whole-of-government and whole-of-society approaches, but considers, nevertheless, that the health sector and health ministers should have the leadership in health promotion. Equity and social determinants have been raised to the focus even more than in earlier programs as a result of the impact of the global WHO Commission on Social Determinants of Health, which drew attention to health equity and actions for redress, and of increasing data on health gaps in Europe. Good governance is necessary for efficient implementation of the principles, and the report Kickbusch and Behrendt 2013 was produced directly to support Health 2020 in governance. It is presented here, though there is a separate chapter on governance. The report is structured to support the implementation by shared governance. It provides policymakers with examples of how the whole-of-government and whole-of-society approaches have been implemented in a wide range of contexts and countries. All these publications are necessary for political and professional leaders and others working with health policy in Europe. WHO Regional Office for Europe 2010, the Parma Declaration and action plan by ministers of both sectors, describes well-established collaboration between health and environment sectors and points out the priorities. WHO Regional Office for Europe 2015 is an example how the organization supports countries in addressing a specific health problem, diet-related noncommunicable diseases.

                Health in All Policies in the European Union

                The health article of the Treaty of European Union establishes HiAP in the Union, and even the term is derived from the article. Health is mainly the responsibility of the member states. However, since many EU policies influence health and health care, the article is extremely important. The report Dahlgren, et al. 1996 is an example of practical external assessment, which made visible the conflict between the obligations of the health article and health-related agricultural policies of the EU, thus having a strong contribution to the development of HiAP principles. Two council conclusions, which can be seen as formal legitimations of the position and agenda of HiAP in European policy, are presented. The first, from 2006, commits the member states and the Commission to follow the HiAP principles; the second, from 2010, focuses on health inequity, which should be addressed by HiAP. Lock and McKee 2005 examines problems of intersectoral health policy after the EU enlargement in 2004. While it is considered that the low status of health in the EU is strengthened by intersectoral policies, the preconditions of the new member states in implementing such policies are not well developed. Health Impact Assessment (HIA) is considered to offer a mechanism to embed public health in sectors in which it is currently marginalized. The six-year health strategy outlined in Commission of the European Communities 2007 had HiAP as one of its four fundamental principles. The aim was to strengthen integration of health into many EU policies, to involve new partners, and to use the approach in external policies, including development, external relations, and trade. In the subsequent strategy, however, HiAP does not have an equally explicit profile. Koivusalo 2010 criticizes the implementation of HiAP by the European Commission. The writer thinks that HiAP at the European level has remained mostly at the level of rhetoric, while European-level decision-making has and will become more important in shaping national policies. There is a lack of structures and mechanisms to address intersectoral public health issues, and existing tools, such as impact assessments, do not pay enough attention to health. Smith, et al. 2010 also criticizes the impact assessment performed by the Commission. The assessment focuses mainly on the impact on the economy and business environment, while health impacts tend to be undervalued. Large tobacco and chemical companies were able to influence the approach and subsequently utilized assessments in attempts to delay, weaken, or prevent legislation intended to promote public health

                • Commission of the European Communities. 2007. Together for health: A strategic approach for the EU 2008–2013. White Paper. Brussels: European Commission.

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                  One of the four fundamental principles of the six-year health strategy is HiAP, and a key action is to strengthen the integration of health concerns into all policies at Community, member state, and regional levels, including the use of impact assessment and evaluation tools.

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                  • Council of the European Union. 2006. Council conclusions on Health in All Policies (HiAP). Proceedings of the 2767th Employment, Social Policy, Health and Consumer Affairs Council Meeting, 30 November and 1 December 2006. Brussels: Council of the European Union.

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                    In its conclusions, the Council invites both the European Commission and the member states to integrate health in all their policies and requests the Commission to establish a work plan for the integration in its next health strategy. This was realized in Commission of the European Communities 2007.

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                    • Council of the European Union. 2010. Council conclusions on equity and Health in All Policies: Solidarity in Health. 3019th Employment, Social Policy, Health and Consumer Affairs Council meeting. 8 June 2010. Brussels: Council of the European Union.

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                      In its conclusions, the Council invites the European Commission, the member states, and the parties together to address health inequities by developing further work on equity and Health in All Policies. A special emphasis on children and youth is mentioned.

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                      • Council of the European Union. 2012. Consolidated versions of the Treaty on European Union and Treaty on the Functioning of the European Union, Article 168. Official Journal of the European Union C 326:1–12.

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                        The Article on Public Health was introduced in the Maastricht Treaty in 1992 and includes small later amendments. It contains the responsibility to high-level health protection in all Union policies and activities—otherwise the powers of the Union to achieve public health objectives would be weak. While health systems remain the competence of the member states, HiAP in principle remains the strongest health policy of the Union.

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                        • Dahlgren, G., P. Nordgren, and M. Whitehead. 1996. Health Impact Assessment of the EU common agricultural policy. Stockholm: Swedish National Institute of Public Health.

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                          A critical assessment focusing on regimes for fruit and vegetables, dairy products, tobacco, and alcohol from a public health perspective. A clear report indicating the incongruence with health targets and making detailed recommendations for a Common Agricultural Policy reform. The recommendations have been partially realized.

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                          • Koivusalo, M. 2010. The state of Health in All policies (HiAP) in the European Union: Potential and pitfalls. Journal of Epidemiology and Community Health 64.6: 500–503.

                            DOI: 10.1136/jech.2009.102020Save Citation »Export Citation »E-mail Citation »

                            The writer criticizes the passive role and narrow scope of the Commission in implementing HiAP principles. The main instrument has been Health Impact Assessment (HIA), but its weight in integrated impact assessment has remained restricted. One concern is that European regulations, based on the aims of other policies, increasingly shape national health systems.

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                            • Lock, K., and M. McKee. 2005. Health Impact Assessment: Assessing opportunities and barriers to intersectoral health improvement in an expanded European Union. Journal of Epidemiology and Community Health 59.5: 356–360.

                              DOI: 10.1136/jech.2004.024026Save Citation »Export Citation »E-mail Citation »

                              A short article on the status of HIA and intersectoral health policy in the EU and the member states, with particular attention to those that joined the EU in 2004. Obstacles are higher in new member states, and HIA is seen as one way to ensure that health is on the broader policy agenda.

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                              • Smith, K., Fooks, J. Collin, H. Weishaar, and A. Gilmore. 2010. Is the increasing policy use of Impact Assessment in Europe likely to undermine efforts to achieve healthy public policy? Journal of Epidemiology and Community Health 64.6: 478–487.

                                DOI: 10.1136/jech.2009.094300Save Citation »Export Citation »E-mail Citation »

                                A literature analysis on impact assessments with special a focus on the integrated impact assessment tool of the EU. Eight fundamental concerns from the health scope were found, most of which suggest that the process can be advantageous to the interests of large corporations and does not necessarily help promote public health interests. The strong and successful lobbying of tobacco and other industries is described.

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                                Social Determinants and Equity in Health in All Policies

                                The core of HiAP is to examine the social determinants of health that can be influenced by policies in sectors other than health. “Social determinants of health” refers to conditions in which people live their lives and the inequalities in these conditions leading to health inequities. Graham 2004 emphasizes an understanding of social processes behind unequal distribution of social factors for policies to address inequity in health. The work conducted by the WHO Commission on Social Determinants of Health (CSDH), reported in Commission on Social Determinants of Health 2008, is the most important international effort to focus on equity. The CSDH produced action recommendations on structural determinants and conditions that cause much of health inequity within and between countries. The Commission had three overarching recommendations: (1) Improve daily living conditions; (2) Tackle the inequitable distribution of power, money, and resources; and (3) Measure and understand the problem and assess the impact of action and a specific recommendation for national governments to engage in Health Equity in All Policies. This Commission was followed up with the World Conference on Social Determinants of Health 2012 and the associated outcome document, the Rio Political Declaration on Social Determinants of Health, which makes explicit reference to leverage points for improving health inequities through five action areas, including adopting better governance for health and development, where intersectoral action and Health in All Policies are emphasized. Blas, et al. 2008 emphasizes that national governments have a strong role in enhancing greater health equity by tackling determinants of health. The fact that many determinants of health equity are beyond the scope of the health sector poses a special intersectoral challenge for tackling crucial factors that determine health equity, such as employment policy, working conditions, and alcohol policies, because there are controversial interests that may hamper the progress, as indicated by Palosuo, et al. 2013, based on experiences in Finland. Reducing inequality in health thus poses a special challenge both in terms of equity-oriented policies and implementation, as noted in Braveman and Gottlieb 2014, which states that great advantages in documenting and understanding the social determinants of health have been made, but unanswered questions about the mechanisms underlying their effects on health have to be updated. The WHO European Review (World Health Organization 2013) can be seen as an example of advocacy to promote equity-oriented policies across sectors that can make a change. The European Portal for Action on Health Inequalities is an example of a practical tool for the study of health equity and of HiAP.

                                • Blas, E., L. Gilson, M. Kelly, et al. 2008. Addressing social determinants of health inequities: What can the state and civil society do? Lancet 372.8: 1684–1689.

                                  DOI: 10.1016/S0140-6736(08)61693-1Save Citation »Export Citation »E-mail Citation »

                                  An article drawing on the wide knowledge networks established by the WHO to support the work of the Commission on Social Determinants of Health. It highlights the role of national governments and civil society in tackling health inequities.

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                                  • Braveman, P., and L. Gottlieb. 2014. The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports 129.S2: 19–31.

                                    DOI: 10.1177/00333549141291S206Save Citation »Export Citation »E-mail Citation »

                                    The article provides an analysis of the term “social determinants” and presents its use and importance in health policymaking. It pays attention to challenges and barriers to understanding the role of social factors in shaping health outcomes and tackling health inequity. It concludes that social factors are so important that there is a compelling need to address them.

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                                    • Commission on Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health; Final report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization.

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                                      The WHO Commission on Social Determinants of Health (CSDH) has captured the main message by saying that social injustice is killing people on a grand scale. The report aims to respond to this by producing recommendations about what should be done to improve health equity. Overarching recommendations are as follows: improve daily living conditions; tackle the inequitable distribution of power, money, and resources; measure and understand the problem; and assess the impact of action.

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                                      • European Portal for Action on Health Inequalities.

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                                        A web portal with information and data on health inequalities across Europe as well as on initiatives, policies, tools, and resources to address them, including searchable case studies. HiAP is regarded as the key policy.

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                                        • Graham, H. 2004. Social determinants and their unequal distribution: Clarifying policy understandings. Milbank Quarterly 82.1: 101–124.

                                          DOI: 10.1111/j.0887-378X.2004.00303.xSave Citation »Export Citation »E-mail Citation »

                                          The article presents social determinants as the key concept for policies to address inequalities in social distribution of health. In policy formulation, it is essential to understand the social processes that lead to an unequal distribution of social factors.

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                                          • Palosuo, H., M. Sihto, E. Lahelma, J. Lammi-Taskula, and S. Karvonen. 2013. Social determinants in the health policy formulations of the WHO and Finland. Helsinki: National Institute for Health and Welfare (THL).

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                                            A report in Finnish (Sosiaaliset määrittäjät WHO:n ja Suomen terveyspolitiikassa), with an English abstract, dealing with the work of the WHO Commission on the Social Determinants of Health and presenting the main ideas of its final report (Commission on the Social Determinants of Health 2008) to the Finnish audience. It compares the basic recommendations of the Commission with the goals of the latest Finnish national public health long-term program (2001) and the national action plan to reduce health inequalities (2008–2011).

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                                            • World Conference on Social Determinants of Health. 2012. Rio Political Declaration on Social Determinants of Health. Geneva, Switzerland: WHO.

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                                              In the Declaration, high-level participants express their determination to achieve social and health equity through action on the social determinants of health using an intersectoral approach. A major challenge is to tackle the inequitable distribution of power, money, and resources. Actions are outlined on five key action areas.

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                                              • World Health Organization. 2013. Review of social determinants and health divide in the WHO European Region: Final report. Copenhagen: WHO Regional Office for Europe.

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                                                A review linking up with the Health 2020 strategy, which is a European policy framework supporting actions across government and society for health and well-being. It supports and provides guidance and recommendations for action on social determinants of health. It is committed to the health equity in all policies approach.

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                                                Governance and Health in All Policies Implementation

                                                During the last few years, several comprehensive reports on governance for health following HiAP principles have been introduced, including WHO Regional Office for Europe 2013 (cited under WHO/EURO and Regional Frameworks for National Action). McQueen, et al. 2012 analyzes governmental structures and actions utilizing many country cases, and also some supranational examples. The main interest is on national governments, but engagement beyond government has also been examined. An important precursor to this work is the discussion paper St-Pierre 2009, with six country cases. Kickbusch has produced many reports on governance for health, Kickbusch and Gleichner 2014 being one of them. It supports the Health 2020 framework program by WHO/EURO. The starting point is a modern society, where power is divided between public authorities, private bodies, media, citizens, and others. Brown, et al. 2013 follows the same thinking on governance but focuses on social determinants and equity. The writers discuss and analyze why equity targets have not been achieved even when they have been set as determined targets. A checklist to facilitate practical work is included. Greer and Lillvis 2014 examines challenges of intersectoral governance utilizing European experiences and literature on public administration and political science. Two kinds of problems are identified: establishment of coordinated actions, and durability in changing political conditions. Well-argued proposals for solutions are proposed, one of them to strengthen political leadership. The writers consider that an important way to achieve and declare the commitment of governments is a prominent intervention by the prime minister, while reports usually emphasize the leadership of the health minister. de Leeuw, et al. 2015 examines governance in the WHO European network of Healthy Cities. The article concludes that the membership of the network has an impact on governance and supports health becoming a more integral part of social and political agendas, leading to better participation, policymaking, and intersectoral action.

                                                • Brown, C., D. Harrison, H. Burns, and E. Ziglio. 2013. Governance for health equity. Copenhagen: WHO Regional Office for Europe.

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                                                  A report describing the attainment of equity in health in European and national policies. Points out that inequities persist and are even increasing despite efforts and good intentions. Analyzes and discusses reasons for the lack of success, presents recommendations, and proposes a checklist for governing for health equity with the whole-of-government approach. Feasible for planners and policymakers.

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                                                  • de Leeuw, E., I. Kickbusch, N. Palmer, and L. Spanswick. 2015. European Healthy Cities come to terms with health network governance. Health promotion international 30 (Suppl. 1): i32–i44.

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                                                    A study on governance in the WHO European Healthy Cities Network during Phase V, generally and classified into four regions. Emphasis on governance resulted in a representation of many non-health sectors, local governments exploited opportunities that external political forces presented to them, and there were positive shifts in partnerships and citizen participation. All cities seemed to benefit to some degree.

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                                                    • Greer, S. L., and D. Lillvis. 2014. Beyond leadership: Political strategies for coordination in health policies. Health Policy 116.1: 12–17.

                                                      DOI: 10.1016/j.healthpol.2014.01.019Save Citation »Export Citation »E-mail Citation »

                                                      A compact article by American writers based on European experiences. Identified problems of intersectoral governance include coordination and durability. Proposed solutions fall into three categories: visible provisions of political will, bureaucratic changes, and indirect methods such as data publication and support from outside groups.

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                                                      • Kickbusch, I., and D. Gleichner. 2014. Smart governance for health and well-being: The evidence. Copenhagen: WHO Regional Office for Europe.

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                                                        Argumentation and delineations for governance for health needed in a society having joint action of health and non-health sectors, of the public and private sectors, and of citizens. Useful for people acting in all sectors of society.

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                                                        • McQueen, D. V., M. Wismar, V. Lin, C. Jones, and M. Davies, eds. 2012. Intersectoral Governance for Health in All Policies: Structures, actions and experiences. Observatory Studies Series 26. Copenhagen: WHO Regional Office for Europe.

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                                                          A well-structured critical analysis of HiAP governance focusing on government structures and actions by separate governmental actors to facilitate policies targeting social determinants of health. Examples from many countries, mainly European, using a variety of tools, are presented. Useful for policymakers, planners, and researchers.

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                                                          • St-Pierre, L. 2009. Governance tools and framework for Health in All Policies. Quebec: National Collaborating centre for Healthy Public Policy.

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                                                            Presents an early methodical look at Health in All Policies in terms of structures, processes, finances, and mandates. Contains case studies of England, Finland, Norway, and Sweden, as well as New Zealand and Quebec. The writer concludes that model of governance and choice of governance tools are highly contextual.

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                                                            Tools for Health in All Policies Implementation

                                                            The WHO Health in All Policies Training Manual (World Health Organization 2015) and associated regional networks of trainers provide training in soft skills relevant across the six action areas. The manual can be seen as a comprehensive tool itself, but it also presents separate tools available in different phases of HiAP process, including Health Lens Analysis and Health Impact Assessment (HIA). The former has been developed and implemented above all in Australia. The latter has been much used in European countries and also by the European Commission. Davies and Lincoln 2014 is a short introduction to HIA. The compact article presents different types of HIA and their use from local-level projects to the EU level. Wismar, et al. 2007 provides a comprehensive examination of the issue, making use of diversified case studies from many European countries. The combining theme is the effectiveness in influencing political decisions in varied policy sectors. The report Fehr, et al. 2014 supports the WHO/EURO policy and examines HIA as both a separate and an integral part of other impact assessments. Simos, et al. 2015 evaluates HIA as an instrument in Phase V of the European Healthy Cities Network. Utilizing a more sensitive and reliable method than used in earlier evaluations, the writers conclude that HIA significantly helps to promote HiAP and sustainability in cities. It promoted equity, participation, partnership, and the position of health in a city’s agenda. Sassi and Belloni 2014 examines fiscal measures as a tool for achieving health targets. The writers present the evidence base and public health rationale for price policies for tobacco, alcohol, food, and nonalcoholic beverages. Economic revenue to states and potential negative effects are also presented. Durand-Zaleski, et al. 2009 presents budgeting for health as a broad target, noting that to address social determinants presupposes a cross-sectoral budgetary process. Grimm, et al. 2013 examines legislation as a state tool to develop HiAP at the local level. It was observed in a sample from Norway that only a few municipalities acknowledged social determinants of health and implemented HIA and health overviews, which were defined as municipalities’ statutory obligations. Further tools of governance, such as fiscal incentives, might be needed to support the implementation of law.

                                                            • Davies, N., and P. Lincoln. 2014. Health Impact Assessment. In Facets of public health in Europe 2014. Edited by Bernd Rechel and Martin McKee, 217–231. European Observatory on Health Systems and Policies Series. Milton Keynes, UK: Open Univ. Press.

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                                                              An article presenting the typology and use of different types of HIA, as well as users of it. Covers all levels (EU, national, local) and emphasizes equity assessment. Considers assessment as a developmental step to HiAP. Consolidates basic knowledge.

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                                                              • Durand-Zaleski, I., K. Chevreul, and G. Jeanblanc. 2009. Financing for Health in All Policies. In Policy innovation for health. Edited by Ilona Kickbusch, 67–94. Geneva, Switzerland.

                                                                DOI: 10.1007/978-0-387-79876-9_3Save Citation »Export Citation »E-mail Citation »

                                                                An article presenting financing for health as a broad target for society, comparing the implications of the Beveredgian and Bismarckian models of social policy. Includes a case study from France. Maintains that a cross-sectoral budgetary process is needed to address social determinants.

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                                                                • Fehr, R., F. Viliani, J. Nowacki, and M. Martuzzi, eds. 2014. Health in Impact Assessments: Opportunities not to be missed. Copenhagen: WHO Regional Office for Europe.

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                                                                  A report examining the assessment of health as a separate health impact assessment and as an integral part of other established impact assessments as well as their usefulness and problems. Concludes that the potentials of impact assessments to promote and protect health are underutilized and that there are alternative ways forward.

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                                                                  • Grimm, M., M. Helgesen, and E. Fosse. 2013. Reducing social inequities in health in Norway: Concerted action at state and local levels? Health Policy 113.3: 228–235.

                                                                    DOI: 10.1016/j.healthpol.2013.09.019Save Citation »Export Citation »E-mail Citation »

                                                                    An article examining legislation as a governmental tool to develop municipal policy, with a specific focus on the implementation of the Norwegian Public Health Act. A great majority of Norwegian municipalities adhered to individual lifestyle- and health-care-related measures, while state strategies focus on the social determinants through the involvement of various political sectors. Also, positive developments were found, and learning from successful municipalities allows for the identification of ways forward.

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                                                                    • Sassi, F., and A. Belloni. 2014. Fiscal incentives, behavior change and health promotion: What place in the Health-in-All-Policies toolkit? Health promotion international 29 (Suppl. 1): i103–i112.

                                                                      DOI: 10.1093/heapro/dau050Save Citation »Export Citation »E-mail Citation »

                                                                      A consolidated and clear review of the impact of tax and other fiscal measures on the consumption and health consequences of alcohol, tobacco, food, and nonalcoholic beverages. Examines the evidence to promote health, as well as potentially undesirable economic and welfare effects.

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                                                                      • Simos, J., L. Spanswick, N. Palmer, and D. Christie. 2015. The role of Health Impact Assessment in Phase V of the Healthy Cities European Network. Health Promotion International 30 (Suppl. 1): i71–i85.

                                                                        DOI: 10.1093/heapro/dav032Save Citation »Export Citation »E-mail Citation »

                                                                        An article with an evaluation of methodology and results. The detailed description is useful for those interested in evaluation methods. The results indicate the usefulness of HIA as a tool for HiAP and are an important lesson to all working with health policy on local level.

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                                                                        • Wismar M., J. Blau, K. Ernst, and J. Figueras. 2007. The effectiveness of Health Impact Assessment: Scope and limitations of supporting decision-making in Europe. Copenhagen: WHO Regional Office for Europe.

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                                                                          A comprehensive book on Health Impact Assessment (HIA). After general chapters, the topics are presented using seventeen case studies across the Europe. The case studies cover many sectors, settings, actors, and processes. Published by WHO/EURO for the European Observatory on Health Systems and Policies.

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                                                                          • World Health Organization. 2015. Health in All Policies training manual. Geneva, Switzerland: WHO.

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                                                                            The training manual covers twelve modules and is being used by national governments as a mechanism to start and support Health in All Policies processes. Health Lens Analysis and HIA are presented as tools for measuring progress in HiAP. The training manual is being used and adapted by a network of trainers, supported by the World Health Organization through its various offices.

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                                                                            Health in All Policies and National Policies

                                                                            Great variation among European countries in social structures, political history, culture, economy, health care systems, and so on leads to multiple solutions in forwarding HiAP. Norway is a typical Nordic welfare society, and Torgersen, et al. 2007 describes the rational policy planning for HiAP. Melkas 2013 looks at past development during four decades in Finland, where major public health challenges have been addressed by consequent multisectoral governmental policy. Storm, et al. 2011 analyzes politics in the Netherlands. The writers cannot see any whole-of-government existing, though there are positive attitudes among policy officers. Many critical remarks are relevant to other European countries. Fox 2013 describes the policy in Scotland, where policy to address health determinants has been linked with policy to increase employment and income. There has been commitment among politicians and officials, but not yet actualization in specific programs. Mattig, et al. 2017 reports the problematics in Switzerland, a highly decentralized country with economic liberalism and a strong business sector. HIA was studied as a first step toward HiAP. Use of HIA did not achieve acceptance on the federal level, and some cantons pioneered to implement it. The writers see that a bottom-up strategy is the most feasible in Switzerland. Axelsson and Bihari-Axelsson 2005 examines intersectoral problems in Russia, where sectors traditionally work as silos and a strong vertical hierarchy makes horizontal collaboration challenging, even between organizations working within public health. Howard and Gunther 2012 includes a literature review and interviews of key stakeholders on implementation of HiAP in twelve EU countries. The scope is the national level and the perspective of EU institutions is missing. WHO Regional Office for Europe 2013 examines the situation in nine southeastern European countries that have met major social upheavals. Though the tradition of multisectorality is weak, politicians seem to have positive attitudes. Recommendations for policy development are given generally and for each analyzed country separately.

                                                                            • Axelsson, R., and S. Bihari-Axelsson. 2005. Intersectoral problems in the Russian organisation of public health. Health Policy 73.3: 285–293.

                                                                              DOI: 10.1016/j.healthpol.2004.11.020Save Citation »Export Citation »E-mail Citation »

                                                                              An article describing the organization of public health in the Russian Federation and analyzing the problems of intersectoral coordination and collaboration. The main challenges are fragmented organization and traditional hierarchic administration, so collaboration across organizational boundaries is difficult. The writers make some suggestions for improving collaboration in order to mobilize all possible resources for public health and to use them in the best possible way.

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                                                                              • Fox, D. M. 2013. Health inequality and governance in Scotland since 2007. Public Health 127.6: 503–513.

                                                                                DOI: 10.1016/j.puhe.2013.04.019Save Citation »Export Citation »E-mail Citation »

                                                                                A study utilizing documents and interviews of persons active in health governance in Scotland. It presents health policy, where health equity and economic growth have been governmental priorities, and they are linked. The study concludes that social, education, housing, employment, and income policies should be developed in collaboration with health policy, particularly with primary care.

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                                                                                • Howard, R., and S. Gunther. 2012. Health in All Policies: An EU literature review 2006–2011 and interview with key stakeholders. Geneva, Switzerland: Equity Action.

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                                                                                  A report presenting the findings of a literature review and interviews of key stakeholders from twelve EU countries or regions. In the conclusions the writers recommend political commitment at the highest possible level, leadership by health systems in advocating for health, and the HiAP approach. Also, country-specific recommendations are given.

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                                                                                  • Mattig, T., N. Cantoreggi, J. Simos, C. Favre Kruit, and D. Christie. 2017. HIA in Switzerland: Strategies for achieving Health in All Policies. Health Promotion International 32.1: 149–156.

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                                                                                    A report on the challenges of developing HiAP in a highly decentralized country. As a first step, HIA has been introduced in three cantons, but on the federal level attempts to institutionalize HIA met too strong a resistance from the business lobby and failed. The writers recommend a bottom-up diffusion strategy, from canton to canton horizontally and up toward the federal level. First published online in 2015.

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                                                                                    • Melkas, T. 2013. Health in All Policies as a priority in Finnish health policy: A case study on national health policy development. Scandinavian Journal of Public Health 41:3–28.

                                                                                      DOI: 10.1177/1403494812472296Save Citation »Export Citation »E-mail Citation »

                                                                                      A description of the forty years of multisectoral health policy in Finland. The policy was initiated by the State Economic Council, developed under the leadership of the Ministry of Social Affairs and Health, delineated during the course by the government and discussed in Parliament, evaluated by international experts, leading finally to large acceptance and a sound legislative basis. A culmination was the theme Health in All Policies during the Finnish EU Presidency.

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                                                                                      • Storm, I., M. Aarts, J. Harting, and A. Schuit. 2011. Opportunities to reduce health inequalities by “Health in All Policies” in the Netherlands: An explorative study on the national level. Health Policy 103.2: 130–140.

                                                                                        DOI: 10.1016/j.healthpol.2011.09.009Save Citation »Export Citation »E-mail Citation »

                                                                                        An analysis of problems of searching for a national HiAP strategy to reduce inequalities in health. The writers argue that the Dutch government does not have a whole-of-government approach. Despite positive attitudes toward intersectoral collaboration in the ministries, the policy officers reported many critical factors for opportunities to collaborate. Some were specific to the Dutch institutional features, but mainly the findings and conclusions are relevant to other European countries.

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                                                                                        • Torgersen, T., O. Giaever, and O. Stigen. 2007. Developing an intersectoral national strategy to reduce social inequalities in health: The Norwegian case. Geneva, Switzerland: World Health Organization.

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                                                                                          A very clear, well-structured, and compact plan to address social determinants of health in Norway. The development of this white paper was planned in the Cabinet and it was built up with the collaboration of seven key ministries. Useful for those working in national health administrations.

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                                                                                          • WHO Regional Office for Europe. 2013. Opportunities for scaling up and strengthening the health-in-all-policies approach in south-eastern Europe. Copenhagen: WHO/EURO.

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                                                                                            A study of current policy in nine formerly socialist southeastern European countries. Provides both general and country-specific recommendations for further development, and useful lessons for other countries considering to building health policy through HiAP.

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                                                                                            Pioneering Health in All Policies in Local Policy

                                                                                            The Healthy Cities program by WHO has for nearly 30 years delineated development of local-level health policy in Europe, and there are plenty of publications on the experiences. From the very beginning, equity, intersectorality, commitment by city leaders, and citizen participation were the leading principles. The article de Leeuw, et al. 2014 evaluates the fifth five-year phase, but also collects the experiences during the whole course. It examines governance and realization of the HiAP approach. The strong role of whole-of-government and the leadership of city mayors are considered important, while in national-level reports and statements the leadership of the health sector is usually emphasized. WHO Regional Office for Europe 2014 presents a case example: a Swedish region targeting mainstream health equity through a multisectoral regional health plan. A clear description of the process provides lessons on enablers, obstacles, and measures to address the challenges. Larsen, et al. 2014 examines a small municipality in Denmark and regards the development and implementation of HiAP as difficult. Real commitment in non-health sectors could not been achieved, the level of ambition was not balanced, and there was need for significant political and public support. In the Netherlands there has been much activity to develop and implement HiAP on local level, and there are many reports analyzing cases and studying the problems generally. Peters, et al. 2014 is an example, in which integrated public health policy by municipalities is classified to the degree of policy integration. To achieve large policy integration, HiAP, it might be helpful to start from the determinants, then move on to policies to tackle them, setting broad policy goals giving actors from all sectors the opportunity to participate. In socialist countries, strong vertical hierarchy was a core principle of administration, and the tradition is still strong in central and eastern European countries. Mannheimer, et al. 2007 analyzes attempts to adopt intersectoral way of working in a Slovakian city during transition. International contacts and political commitment seem to support the development toward HiAP. de Blasio, et al. 2012 describes the same problems in a Hungarian city belonging to the WHO/EURO Healthy Cities Network. Even careful planning and a training program did not create commitment to adopt a simple health-targeting decision-supporting tool among non-health sector officers in the city administration. Warner and Gould 2009 presents networks as instruments to change the practice at the local level to comply with national intentions. The idea of “Virtual Reorganization by Design” was applied in a local community in Wales, and national-level targeting was made operational across multiple sectors on a networked and integrated basis.

                                                                                            • de Blasio, A., J. Giran, and Z. Nagy. 2012. Potentials of Health Impact Assessment as a local health policy supporting tool. Perspectives in Public Health 132.5: 216–220.

                                                                                              DOI: 10.1177/1757913910391039Save Citation »Export Citation »E-mail Citation »

                                                                                              An unsuccessful story from Hungary. Careful planning and training of officials in many sectors of city administration did not lead to realization of a HIA filter as a decision-supporting tool in the city council. The writers consider that the main causes of the failure were the missing self-confidence and motivation of the trained officials and the lack of involvement of decision makers.

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                                                                                              • de Leeuw, E., A. Tsouros, M. Dyakova, and G. Green. 2014. Healthy Cities: Promoting health and equity-evidence for local policy and practice. Copenhagen: WHO Regional Office for Europe.

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                                                                                                An evaluation of Phase V after twenty-five years of the still ongoing Healthy Cities program. Many positive developments are reported from participating cities, where the HiAP approach has been adopted, and HIA utilized as a tool. The leadership role of city mayors is emphasized. The optimistic report strives for adoption and implementation of the principles of the program in the participating cities as well as in other cities in Europe.

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                                                                                                • Larsen, M., R. Rantala, O. Koudenburg, and G. Gulis. 2014. Intersectoral action for health: The experience of a Danish municipality. Scandinavian Journal of Public Health 42.7: 649–657.

                                                                                                  DOI: 10.1177/1403494814544397Save Citation »Export Citation »E-mail Citation »

                                                                                                  An evaluation of the process of development and implementation of an intersectoral health policy in a small municipality. The main challenge was to achieve real commitment in non-health sectors. Facilitating factors were political support, public involvement, use of local media, financing, and networking over sectors.

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                                                                                                  • Mannheimer, L. N., G. Gulis, J. Lehto, and P. Ostlin. 2007. Introducing Health Impact Assessment: An analysis of political and administrative intersectoral working methods. European Journal of Public Health 17.5: 526–531.

                                                                                                    DOI: 10.1093/eurpub/ckl267Save Citation »Export Citation »E-mail Citation »

                                                                                                    An analysis of enablers and barriers in adopting a new intersectoral way of working at the local level in Slovakia during transition. The obstacles were strong health-care focus and the lack of knowledge and experience on intersectorality. Enablers were the membership of international organizations calling for new solutions and political commitment believing in positive health effects of intersectorality.

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                                                                                                    • Peters, D., J. Harting, H. van Oers, J. Schuit, N. de Vries, and K. Stronks. 2014. Manifestations of integrated public health policy in Dutch municipalities. Health Promotion International. Online first publication (10 December).

                                                                                                      DOI: 10.1093/heapro/dau104Save Citation »Export Citation »E-mail Citation »

                                                                                                      The writers classify local integrated public health projects according to increasing integration into three classes, intersectoral action, healthy public policy, and HiAP. Manifestations had more characteristics of intersectoral action than HiAP, and increasing policy integration was related to broad goal definitions. In conclusion, the nature of the public health problems addressed define the necessary level of integration.

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                                                                                                      • Warner, M., and N. Gould. 2009. Integrating Health in All Policies at the local level: Using network governance to create “virtual reorganisation by design.” In Policy Innovation for Health. Edited by Ilona Kickbusch, 125–163. New York: Springer-Verlag.

                                                                                                        DOI: 10.1007/978-0-387-79876-9_5Save Citation »Export Citation »E-mail Citation »

                                                                                                        A report in two parts. A theoretical part reviews different types of networks, network governance, constructing network design, virtual coordination, and other factors. It is followed by a case study at the local level in Wales, in which “virtual reorganization by design” was used to facilitate practical intersectoral action.

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                                                                                                        • WHO Regional Office for Europe. 2014. Tackling health inequalities from concepts to practice: The experience of Västra Götaland. Copenhagen: WHO/EURO.

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                                                                                                          A description of a process to mainstream the health equity dimension in a regional health plan. An account of factors that made it possible, of obstacles encountered, and of the measures taken to overcome them. An example of the implementation of the whole-of-society approach in a real setting. Useful lessons to those working at the local or regional level.

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                                                                                                          Opportunities and Challenges in Health in All Policies

                                                                                                          This section presents articles debating or analyzing problems of HiAP development and implementation. de Leeuw and Peters 2015 analyzes the complexity of determination of health and health inequity, and also HiAP as a way to influence them. The writers set nine fundamental questions, starting from a definition of the problem and ending in a description and planning of implementation. Koivusalo 2014 examines potential threats to national health policies by trade and investment agreements. Agreements may restrict the policy space for health in many sectors, the health sector included. Bacigalupe, et al. 2010 presents debates against neoliberalism and individualism and argues for putting in practice the Ottawa principles. The writers think that current health promotion hampers social change, as it does not fundamentally question the structures of power and the socioeconomic development model. They see HiAP as an opportunity to overcome resistance. As a step forward, HIA should be used in wider social and macroeconomic projects. Raphael 2014 discusses powers that work against healthy public policy, targeting an equitable distribution of social determinants of health. The main focus is on Canada, but European countries, divided into four categories, are also interestingly analyzed. Division of power, influence, and resources in society are a result of political struggle, and the business and corporate sector, strengthened by neoliberal ideology, is the main opposing actor. Bert, et al. 2015 sees HiAP as a response to emerging European and worldwide threats to welfare and health, like the aging of society, climate change, increased health inequalities, and the financial crisis. The difficulty is to bring health into the agenda of policy sectors. The leadership of the central government is important, as is making visible the contribution of each sector. Bert and colleagues emphasize that the size of health gaps within the EU is still huge and inconsistent with EU core values. Parker, et al. 2010 calls for new ways to boost HiAP to the agendas of policymakers. The writers argue that quantitative evidence is the best way to make decision makers from non-health sectors understand the benefits of their measures and delineate the development of statistical indicators and a research agenda. Hendriks, et al. 2014 studies the operationalization of integrated public health policies targeting health-promoting behavior. It utilizes as a theoretical framework the Behavior Change Wheel, based on motivation, capability, and opportunity, and proposes criteria for pathways in the process toward the formulation of integrated policy. Shandkarness, et al. 2012 presents a literature review of cases of intersectoral action for health equity. Half of the countries represented in the report are European. The writers found the descriptions of these complex, multi-actor processes generally superficial and sometimes absent, implicating a major challenge for researchers.

                                                                                                          • Bacigalupe, A., S. Esnaola, U. Martin, and J. Zuazagoitia. 2010. Learning lessons from past mistakes: How can Health in All Policies fulfil its promises? Journal of Epidemiology and Community Health 64.6: 504–505.

                                                                                                            DOI: 10.1136/jech.2010.110437Save Citation »Export Citation »E-mail Citation »

                                                                                                            A critical debate intervention from Spain on the implementation of the Ottawa Charter. The main challenge is the spread of neoliberalism and the underlying values of individualism and materialism while many determinants of health are out of the reach of individuals, communities, and even states. The initiative on HiAP is seen as invaluable, and HIA as a possible tool to shift the rhetoric to real action.

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                                                                                                            • Bert, F., G. Scaioli, M. Gualano, and R. Siliquini. 2015. How can we bring public Health in All Policies? Strategies for healthy societies. Journal of Public Health Research 4.1: 393.

                                                                                                              DOI: 10.4081/jphr.2015.393Save Citation »Export Citation »E-mail Citation »

                                                                                                              Italian writers debate opportunities to forward HiAP in EU and European national and local policies. Lack of evidence and latency of time between implementation of policy and health outcomes are obstacles. They emphasize that intersectoral collaboration depends on vision and leadership of the central government, and they recommend utilization of media, including improving scientific competences of journalists by national public health institutes, in order to create commitment to HiAP.

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                                                                                                              • de Leeuw, E., and D. Peters. 2015. Nine questions to guide development and implementation of Health in All Policies. Health Promotion International 30.4: 987–997.

                                                                                                                DOI: 10.1093/heapro/dau034Save Citation »Export Citation »E-mail Citation »

                                                                                                                The Dutch and Australian writers illustrate fundamental problems of HiAP and construct a checklist useful for those developing or practicing HiAP. Their style is easy to read and refreshed with sophisticated humor, while discussing the topics in depth.

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                                                                                                                • Hendriks, A., J. Habraken, M. Jansen, et al. 2014. “‘Are we there yet?”—Operationalizing the concept of Integrated Public Health Policies. Health Policy 114.2–3: 174–182.

                                                                                                                  DOI: 10.1016/j.healthpol.2013.10.004Save Citation »Export Citation »E-mail Citation »

                                                                                                                  A report looking for better operationalization of integrated public health. It consists of a literature review, identification of gaps in the operationalization, search of conceptual approaches to fill the gaps, and proposals for operational criteria. The Behavior Change Wheel is used as an instrument, while health-promoting behavior is seen as the goal of policy.

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                                                                                                                  • Koivusalo, M. 2014. Policy space for health and trade and investment agreements. Health Promotion International 29:29–47.

                                                                                                                    DOI: 10.1093/heapro/dau033Save Citation »Export Citation »E-mail Citation »

                                                                                                                    An analysis of implications and threats to health and health systems caused by trade agreements. Presents a screening checklist for health-relevant provisions in agreements, with commentary. Practical for those who have to defend health in the EU, national governments, and NGOs.

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                                                                                                                    • Parker, L. A., B. Lumbreras, and I. Hernandez-Aguado. 2010. Health information and advocacy for “Health in All Policies”: A research agenda. Journal of Epidemiology and Community Health 64.2: 114–116.

                                                                                                                      DOI: 10.1136/jech.2008.081976Save Citation »Export Citation »E-mail Citation »

                                                                                                                      Spanish writers outline the research needed for placing health on the agendas of all policymakers. They find three priority areas: research that provides quantitative evidence linking social and environmental determinants with health outcomes; research that quantifies the effect of policies and interventions on these determinants; and the development of policy-linked indicators that provide a quantitative estimate of the health gain of a specific policy.

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                                                                                                                      • Raphael, D. 2014. Beyond policy analysis: The raw politics behind opposition to healthy public policy. Health Promotion International 30.2: 380–396.

                                                                                                                        DOI: 10.1093/heapro/dau044Save Citation »Export Citation »E-mail Citation »

                                                                                                                        An article examining how politics of power, influence, and resources is related to equity-targeting healthy public policy. European countries are divided according to welfare regimes into four categories: liberal, social democratic, conservative, and Latin. The business and corporate sector and the neoliberal ideology behind them are seen as the main opposing actor.

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                                                                                                                        • Shandkarness, K., O. Solar, K. Murphy, L. Greaves, and P. O´Campo. 2012. A scoping review of intersectoral action for health equity involving governments. International Journal of Public Health 57:25–33.

                                                                                                                          DOI: 10.1007/s00038-011-0302-4Save Citation »Export Citation »E-mail Citation »

                                                                                                                          A review of 128 articles from 43 countries, half of them European. The distribution of cases suggests that intersectoral approaches are feasible in a variety of social, economic, and political systems. There was information on how such approaches were used, but generally the description of these complex processes was superficial. Most articles were written either from the perspective of one sector, often health, or from an academic perspective.

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