Health in All Policies in European Countries

by

Tapani Melkas, Marita Sihto

• LAST REVIEWED: 22 December 2022
• 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.

  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.

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

  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.

• 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.

  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.

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

  DOI: 10.1177/1403494810379895

  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.

• 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.

  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.

• 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.

  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.

• 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.

  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.