health in all policies – applying the governance lens
Whole-of-society and whole-of-government responsibilities for health will be driven by a high degree of political commitment, enlightened public administration and societal support. making this responsibility meaningful and functional requires concrete intersectoral governance structures that can facilitate the requisite action, with the aim of including, where appropriate, health in all policies, sectors and settings. These intersectoral governance structures are equally relevant for governments, parliaments, administrations, the public, stakeholders and industry.
The aim of a whole-of-society approach is to expand whole-of-government thinking by emphasizing the roles of the private sector and civil society and a wide range of political decision-makers, such as parliamentarians. The policy networks that have emerged within government increasingly extend
beyond their boundaries to include other social actors. The whole-of-society approach implies additional capacity for communication and collaboration in complex, networked settings and highlights the role of the media and new forms of communication. Each party must invest resources and competence.
By engaging the private sector, civil society, communities and individuals, the whole-of-society approach increases the resilience of communities to withstand threats to their health, security and well-being. As stated by Paquet (287): “Collaboration is the new categorical imperative”. The whole-of-society approach goes beyond institutions: it influences and mobilizes local and global culture and mass media, rural and urban communities, and all relevant policy sectors, including education, transport, the environment and even urban design, as can be demonstrated with respect to obesity and the global food system. Whole-of-society approaches are forms of collaborative governance that emphasize coordination through normative values and trust-building among various actors in society. The approaches usually imply steering instruments that are less prescriptive, less committed to a uniform approach, and less centralized and hierarchical. Joint goals and targets, such as Healthy people 2020 in the united States of America (288), are a good starting point. many Eu policies have a similar basis, given the wide consultation that precedes them, usually involving all relevant stakeholders, public as well as private, although not with the same level of influence.
nevertheless, governments must retain the ultimate responsibility for and commitment to protecting and promoting the health and well-being of the people they serve and the societies they reflect. At all levels in society, political commitment is absolutely vital to focus the responsibility and accountability for improving health and well-being. Thus, governance for health and health equity will require governments to strengthen the coherence of policies, investment, services and action across sectors and stakeholders. Synergistic policies are required, many of which reside outside health, supported by structures and mechanisms that foster and enable collaboration. many determinants of health and health equity are shared priorities with other sectors, such as improving educational performance, promoting social inclusion and cohesion, reducing poverty and improving community resilience and well-being. These provide a convening point for action across sectors that will produce benefits for health and health equity (289). There is a clear role for health impact assessment to bring health and other policy outcomes into a common frame of analysis.
Achieving whole-of-government governance for health is difficult and challenging. much more is required than a simple mandate (290). In addition, the evidence to support intersectoral governance is often scarce, partial, inconclusive or anecdotal. However, progress is possible, as shown by lessons from the fields of sustainability and development. A key action area is developing new or strengthened instruments and mechanisms that ensure equity of voice and perspectives in decision-making processes. Effective governance for health employs collaborative models of working to increase resource flows; to improve the distribution of determinants, affecting the opportunity to be healthy; to redress the current patterns and magnitude of health inequities; and to reduce the risks and effects of disease and premature mortality across the whole population.
The findings of the Task Group on Governance and Delivery Mechanisms (291), one of the task groups linked to the European review of social determinants of health and the health divide (17), indicate that interventions to address the social determinants of health and tackle health inequities usually require improved systems of governance and delivery. These will need to operate at all levels of governance, involving both the whole of society and the whole
of government, and to provide both a national as well as a local context for action on health. The Task group has identified several main reasons why governance and delivery systems fail to address the social determinants of health and related health inequities:
• a failure to conceptualize and act on the full causal pathway leading to the desired outcome of reduced health inequities (conceptual failure);
• a failure to construct an effective delivery chain and supportive incentives and organizational mechanisms capable of delivering improved outcomes in terms of social determinants of health and health inequities (delivery chain failure); and
• a failure to develop a control strategy that oversees the overall delivery process (government control strategy failure).
This last failure is often linked to weak capacity to identify and quickly rectify a wide range of shortcomings, such as organizational, financial and legislative inadequacies and other causes of underperformance.
Thus, member States may consider several preconditions and measures needed to “make it happen” and increase their governance performance. A review of studies that have analysed progress in this domain throws light on important lessons and opportunities to reduce the failures outlined above (291).
In making progress towards adopting a society and whole-of-government approach to taking action for reducing health inequities, several innovative practices and tools are now available for countries to consider and adapt to their specific contexts, nationally and subnationally.
The following principal developments may be especially relevant.
• Government structures. At the cabinet table, ministers can develop joint policies either under the auspices of the head of government or through collaboration between selected ministries. Cabinet subcommittees may be formed to deal with health issues as part of a whole-of-government approach, with mechanisms to promote a common understanding of solutions. Institutional platforms can be used, such as a jointly staffed health policy unit embedded in the prime minister’s office, or joint committees or working groups. Interdepartmental committees may facilitate the provision of evidence and the development and coordination of policy.
Keeping the issues of health and development alive and influential may require a small, dedicated resource unit moving freely across communities and sectors, creating and promoting regular dialogue and platforms for debate. Providing a legal mandate reflects high-level support for action on the social determinants of health.
• Mega-ministries and ministerial mergers. These have been introduced in an attempt to enhance the efficiency and coherence of political and administrative work in government. While the argument for such changes might appear compelling, the evidence for increased intersectoral coherence is not.
• Public health ministers. These may have an explicit intersectoral mandate to support whole-of-government action for health. They may be supported by a high-level national steering committee composed of representatives of key national, regional and local authorities and agencies.
• Ministerial links and strategic alliances. These bring together otherwise separated if not isolated policy fields at top decision-making level. There are different approaches to establishing policy coherence at the cabinet level. Such cross-government alliances among policy sectors can be incentivized through a range of mechanisms that are mutually reinforcing and hold key sectors accountable. One approach sees cabinet ministers together developing a policy, with each of them owning a limited number
of targets in the joint policy, aligning sub-targets with each other so that policy goals do not conflict. Another possibility for establishing ministerial links is to commission policy frameworks from the finance ministry for each ministry. Such mechanisms for ensuring joint targets and common shared goals, backed up by statements of mutual responsibility, are proving effective in this regard, particularly when they are understood as being one way for organizations to share risks and hold each other accountable (293).
• Shared and pooled budgets. The current economic difficulties that governments are facing throughout the European Region may force policy sectors to work in a different and more cooperative manner, thus making the notions of “whole-of-government” and “whole-of-society” operational and able to address issues related to health inequities and their social determinants. Countries are already using some new mechanisms that can help build and sustain strategic alliances across sectors. Shared and pooled budgets among policy sectors can promote the development of new accounting methods and the creation of new funds. Examples are found in South Australia and are also emerging in Europe, mainly at the subnational level (294). These mechanisms can integrate financial incentives and reward systems that foster the vertical and horizontal integration needed to reduce health inequities. In some cases, they can also include sharing and rotating human and other resources across sectoral boundaries, as a means of strengthening intersectoral collaboration and trust (295).
• Joint review of policies and interventions. These tools are increasingly used in whole-of-government approaches, in order to promote intersectoral action and cooperation. For example, some countries in the Region involved in action plans to improve the health of the Roma population use joint reviews of policies, and they have been recommended notably in the four key policy areas of education, housing, employment and health (296).
• Evidence support. Evidence support helps people develop a common understanding of facts, figures, analysis and interpretations. This creates common ground for dialogue and evaluation of joined-up policies, programmes and projects, to allow shared learning and mutual adjustment as these policies are developed and implemented and to sustain commitment and sustainability over time (291).
• Reaching out. governments need to reach out when trying to engage people, patients and societal stakeholders, including the private sector as appropriate. Public consultations, state health conferences and thematic platforms have served this purpose. Such advocacy can relate to government policies, laws and regulations that are designed to favourably modify health-related issues such as taxation, marketing and advertising arrangements. Advocacy may aim not only to induce acceptance of legal changes but also to promote a shift in attitudes, culture, and social and physical environments