Health in All Policies Explained: A Public Health Framework

This comprehensive section covers the foundational concepts of Health in All Policies (HiAP) and its practical implementation across multiple local authorities. Alan Higgins explains that HiAP is an approach to public policies across sectors that systematically takes into account health implications of decisions, seeks synergies with other policies, avoids harmful health impacts, and aims to improve population health and health equity. The WHO adopted this approach in the 2013 Helsinki Statement. Seven key benefits include promoting health equity and sustainability, creating structural change, engaging diverse stakeholders, and developing monitoring tools. Evidence from a BMJ 2017 study demonstrates that during the national health and equality strategy period, the gap in life expectancy between deprived and less deprived populations stopped increasing and began to close. The Liverpool City Region Wealth and Well-being Program found that about one-third of the productivity gap was attributable to ill health, particularly mental health. Basildon Council's 'health lens' approach involves considering health in every decision despite not having statutory health responsibilities, engaging diverse stakeholders, and applying health lens to all services including waste collection and procurement. Hertfordshire County Council developed a prevention policy emphasizing health implications in decisions, collaboration, focus on inequalities, and evidence-based decision-making, implementing a strategy to comment on planning applications over 100 dwellings.

Louisville Metro Department of Public Health and Wellness established a Center for Health Equity in 2006, expanding to 40 personnel by 2018. The center focuses on social determinants of health and equity issues. Louisville's lead burden is concentrated in West Louisville due to historical redlining practices, with approximately 150 cases of elevated blood lead levels handled by only three staff members. HiAP implementation focused on developing cross-sector relationships with water companies, HUD Lead Hazard Control programs, and refugee agencies. Key activities included forming the Lead and Healthy Homes Collaborative, securing grants for laboratory capacity, enhancing case management databases to track housing information, creating unified program messaging, and developing community-inspired communications campaigns. Successes included improved referral management through Unite Us platform, enhanced data integration, and strengthened relationships with WIC, asthma programs, and housing authorities. Challenges included staff capacity limitations and sustained community engagement requirements.

Health in All Policies (HiAP) is an upstream intervention approach that fundamentally changes government governance to integrate health considerations into all policy sectors (such as transportation, taxation, and housing) through inter-sectoral collaboration, with the goal of addressing structural determinants of health and reducing health inequities across marginalized communities; this approach requires policy coordination across multiple government levels, evidence-informed decision-making, and is implemented differently across jurisdictions (e.g., Quebec's mandatory health impact assessments, Sweden's strategic health frameworks, California's sustainability-focused policies) rather than following a single cookbook model.

Health in All Policies (HiAP) is an intersectoral approach that systematically considers health consequences of decisions across government sectors to improve population health and equity. Successful local implementation requires: (1) action-oriented mandates that motivate participants by showing tangible impacts and quick wins; (2) structured open communication in meetings to build trust, identify shared objectives, and co-create solutions; (3) coordination across government levels and with community partners; and (4) evidence-based policy development. Local governments are particularly well-positioned to influence social determinants of health through transportation planning, land use decisions, and community engagement.

Health in All Policies (HiAP) is an approach to public policies across sectors that systematically considers health implications of decisions to improve population health and equity. Based on research from five Canadian case studies in Ontario and Québec, successful HiAP implementation at the local level requires two key strategies: (1) maintaining an action-oriented focus where initiatives demonstrate tangible impacts and achieve early wins within 12 months to keep participants motivated, and (2) facilitating open communication among diverse stakeholders to build trust, identify shared goals, and develop holistic understanding of community issues. Local governments are uniquely positioned to address social determinants of health through land use planning, transportation, and community partnerships, though they face challenges including securing sustainable funding, navigating political changes, and maintaining committee engagement over time.

Silos limit effective health equity work through topic-based, data-sharing, funding, role-based, geographic, and temporal boundaries. Overcoming silos requires rotating meeting times and locations to accommodate different schedules and community spaces; offering materials in multiple languages; engaging organizational partners who already connect with affected populations; building relationships before needing support; and bringing whole selves with diverse identities and skills. These strategies challenge organizational norms and enable cross-sector collaboration necessary for addressing complex health equity issues. Recognizing that silos exist at multiple scales—from organizational buildings to national policies—helps practitioners develop more effective approaches to collaborative work.

This panel examines barriers to creating cross-sector collaborations that deliver real health results. Poll results identified institutional systems that disincentivize partnership (50%), stakeholders infrequently connecting due to long-standing silos (40%), and funding gaps (surprisingly ranked third). Healthcare is described as a system of systems rather than a single system, intertwining economics, care delivery, and social issues. The pandemic demonstrated what collaboration can achieve when healthcare systems, politicians, public health, and business communities work together on a single issue. Community health needs assessments reveal geographic variations in priorities, with some communities identifying gun violence as a top health concern. Solutions require making the economic case for health investment and engaging policy and business communities in health improvement. The panel emphasizes that resources are becoming more scarce, making cross-sector collaboration even more essential.

Achieving health equity requires policy change at national, state, and local levels, which requires cross-sector collaboration. The Robert Wood Johnson Foundation's Policies for Action program examines how policies and laws at different levels lead to tangible health outcomes. The challenge is that federal funding comes in different pots and at different times, making it difficult to coordinate solutions. At the local level, silos between agencies (like transportation, health, and housing) make it difficult to address interconnected issues. Getting people to step out of their silos and work together is essential. Effective cross-sector health leaders need three historic roles: (1) Donkeyote—having the vision, which must come from deeds, not just words, because communities will judge by what you do; (2) Robin Hood—shifting resources and getting resources to where they are needed, including at the federal government level; (3) Prince Machiavelli—innovating what we don't even know today, bringing in resources from other sectors. A fourth skill is empathetic listening, which is often missing in cross-sector collaboration. Creating line of sight across organizations means helping people understand how their work impacts health outcomes.

Effective toxic stress intervention requires breaking down artificial silos between healthcare, education, and social service sectors. Pediatricians and internists care for the same patients across lifespans yet operate separately; universities maintain separate schools; governments operate through disconnected departments. The science of toxic stress provides a unifying framework cutting across health, education, economics, and social welfare. Federal leadership models inter-agency collaboration through joint Department of Health and Education initiatives, the Race to the Top Early Learning Challenge, and grants for state coordination. States like Washington are developing programs where interventions addressing parenting skills simultaneously improve child development, parental employment, and meet work requirements for public assistance. This demonstrates how shared science can create efficiencies across traditionally disconnected systems.

Effective cross-sector collaboration requires rethinking leadership for the 21st century, with leaders needing 'steroids'—relational qualities including developing relationships, quietness, and ego management. Leadership is ubiquitous, requiring many people in collaborations to demonstrate leadership capabilities. Sectors are fundamentally different despite seeming similar, necessitating investment in cross-sector understanding early in careers. Power imbalances cannot be left to balance naturally—they require deliberate action. In refugee housing examples, government voluntarily gave away power rather than maintaining control, enabling outcomes much more positive than traditional approaches. Trust is not an input but an outcome of how you operate, requiring deliberate structuring and time investment. Organizations must think around who needs to be in conversations, how to build networks deliberately, and structure trust-building appropriately. The SAPP framework provides maturity assessment across five levels of interactive working together. Without common language and taxonomy, people use the same words for very different phenomena, hindering effective collaboration. Addressing these institutional and interpersonal barriers requires sustained commitment to collaborative practice.

Logic models help structure HiAP evaluation by mapping activities to short-term outcomes that can be measured, while acknowledging that intermediate and long-term outcomes are influenced by many factors. Key activity areas include strengthening partnerships, mobilizing knowledge, and building capacity. Both process evaluation (how work is done) and outcome evaluation (what results are achieved) are important. Evaluation should inform ongoing improvement rather than solely serving to justify existence to funders.

Success in HiAP can be evaluated through three dimensions: (1) Collaboration mechanism effectiveness—how successful intersectoral work processes meet expectations of agencies involved; (2) Policy process changes—whether public policy decision-making processes have integrated health considerations; (3) Policy impacts—whether goals of other agencies have changed, social determinants dashboards show positive changes disaggregated by socioeconomic status or ethnicity, and health inequalities are decreasing. Monitoring must track progress over time. For stakeholder engagement, success requires champions at all levels who advocate for collaboration, bidirectional relationships where other sectors understand their health impacts, and using common language that resonates with different audiences. International organizations can help promote health as universal right and civilizational priority.

Better health represents the longest-term outcome in a measurement chain. It can be measured through corollary indicators—specifically, someone with poor health visits the GP often. Therefore, improved health can be quantified by measuring the reduction in the number of GP visits over time.

Evaluating HiAP initiatives requires balancing short-term accountability demands with long-term health outcomes. Under year-to-year funding pressures, focusing on intermediary outcomes—specific policies implemented, partnerships developed, and environmental changes—is more practical than tracking ultimate health effects. This approach links tangible community changes to health and well-being through existing literature. Citizen engagement in HiAP remains limited, with traditional advocacy roles persisting despite calls for more direct participation. Some local examples feature community tables including government, public health, business, and organizations, but broader citizen navigation of government health interactions remains underdeveloped. HiAP benefits extend beyond health to education, transportation, and other sectors, requiring frameworks to identify and measure cross-sectoral outcomes. The reframing of HiAP as 'well-being in all decisions' may overcome resistance, as different communities prefer terms like 'wellness' over 'health.' Linking HiAP to Sustainable Development Goals offers potential for strengthening legitimacy and accessing international resources, though this connection requires further exploration.

Health in All Policies (HiAP) is a strategic concept addressing population health and wider determinants at decision-making levels. It relates to public policies, health equity, and rights. HiAP emerged from EU treaties requiring health protection in all Union policies, providing leverage for health ministries. It is complementary to concepts like Whole of Government and Whole of Society. HiAP should be applied where policy decisions are made, across global, national, and local levels. Kingdon's three streams approach helps practitioners understand solutions, political chances, and policy opportunities. The key is knowing specific health goals to achieve meaningful outcomes.