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WHO Collaborating Centre on Health in All Policies and the Social Determinants of Health

HiAP at global level

WHO resolutions and global statements on HIAP

Looking back at the history of HiAP and declarations, resolutions and statements that have established the position of the approach, there are milestones in global action and WHO global health promotion conferences.World Health Assembly resolutions on HiAP and intersectoral action are cornerstones of this evolution.

The Alma-Ata Declaration, adopted at the WHO conference in 1978, brought up intersectoral action in the context of primary health care and outlined the evolution of the HiAP approach on a global scale. The Declaration stressed the essential relevance of human right to health, and the greatest possible fulfillment of these rights necessitates.1

The Alma-Ata Declaration was followed by Ottawa Charter in 1986. This was an outcome from the first global health promotion conference by WHO and it emphasized the Healthy Public Policy -approach, commitment to health promotion and an intersectoral cooperation. According to the Charter, everyone’s basic health needs, such as security, education, healthy environment, and social justice, should be protected.2

The more recent WHO global health promotion conferences and statements have endorsed the health promoting environments (Sundsvall Statement, 1991) and focused to safeguarding health promotion frameworks, new global challenges, and cross-sectoral collaboration (Jakarta Declaration, 1997).3,4

Adelaide Statement (2010) stressed the HiAP approach and joined-up governance principles at all levels of government and stakeholders.5 Global WHO health promotion conferences have also been complemented by meeting on social determinants of health and the Rio Political Declaration (2011) which also highlights global intersectional action as well.6

The eighth global conference on global health promotion was organized in Helsinki in 2013.  Helsinki statement had specifically focus on Health in All Policies and a “Framework for country action” was delivered. This statement called for the use of HiAP approach, through the policymakers’ responsibility for health, policy coherence and transparency, and cross-sectoral action.7

The most recent declaration by WHO was in October 2018, when the Global Conference on Primary Health Care gathered leaders of state and government in Astana, Kazakhstan, to adopt a new declaration. The Astana Declaration‘s first obligation is to “make bold political choices for health across all sectors.”8

Additionally, UN’s Sustainable Development Goals can also be seen as health in all policies -kind of an approach, as all the goals have an impact on public health.9

Sources:

  1. World Health Organization (WHO) 1978. Declaration of Alma-Ata. Available from http://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdf?ua=1
  2. World Health Organization (WHO) 1986. Ottawa Charter for Health Promotion. Available from http://www.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.pdf?ua=1
  3. World Health Organization (WHO) 1991. Sundsvall Statement on Supportive Environments for Health. Available from https://apps.who.int/iris/bitstream/handle/10665/59965/WHO_HED_92.1.pdf;jsessionid=B448BF21D28F5030F38BE1C01FE2C506?sequence=1
  4. World Health Organization (WHO) 1997. The Jakarta Declaration on Leading Health Promotion into the 21st Century. Available from https://apps.who.int/iris/bitstream/handle/10665/63698/WHO_HPR_HEP_4ICHP_BR_97.4_eng.pdf?sequence=1
  5. World Health Organization (WHO) 2010. Adelaide Statement on Health in All Policies: moving towards a shared governance for health and well-being. Available from https://www.who.int/social_determinants/hiap_statement_who_sa_final.pdf
  6. World Health Organization (WHO) 2011. Rio Political Declaration on Social Determinants of Health. Paper presented at the World Conference on Social Determinants of Health. Available from https://www.who.int/sdhconference/declaration/Rio_political_declaration.pdf?ua=1
  7. World Health Organization (WHO) 2014. Health in all policies: Helsinki statement. Framework for country action. Available from https://apps.who.int/iris/bitstream/handle/10665/112636/9789241506908_eng.pdf?sequence=1&isAllowed=y
  8. World Health Organization (WHO) 2018. Global Conference on Primary Health Care. Available from https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf
  9. United Nations: The 17 goals 2021. Available from https://sdgs.un.org/goals [Read in Nov 2021]

European Union and HIAP

The importance of high level of health protection was included already in the Treaty of Amsterdam as Article 152.1 Intersectoral action was reflected in occupational health but did not gain a clearer role on the earlier EC agenda. However, the emphasis on HiAP became more explicit during the Finnish EU presidency in 2006. Article 168 of the Treaty on the Functioning of the European Union states that “A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities.”2

The White Paper “Together for Health – A Strategic Approach for the EU, 2008-2013” proposed a broad cross-policy framework to react comprehensively and coherently to a wide variety of health concerns. These included strengthening European defenses against health risks, improving cancer prevention and early detection, and providing individuals with the resources they need to make informed health decisions.3

The importance of focusing on equity and health in all policies has been reinforced in Council conclusions from 2006, 2010, and 2011, stating that “A ‘Health in all policies’ approach with an equity focus should be used in specific policy areas and coordinated activities that have the greatest health impact contributing to reducing the persisting health gaps. This might include health, education, research, environment, agriculture, economy, employment and social policies.”4

The HiAP approach in Europe has remained widely articulated, but less widely implemented. European Union competence is more prominent in commercial and economic policies with the consequence that health systems, public health, and health promotion can become subservient to the goals of other policies. This applies also to the EU Treaty obligation to ensure a high level of health protection in all policies as it has been difficult to achieve in practice.5,6

Sources:

  1. EUR-lex 2008. Treaty establishing the European Community (Nice consolidated version) – Part Three: Community policies – Title XIII: Public health – Article 152 – Article 129 – EC Treaty (Maastricht consolidated version) – Article 129 – EEC Treaty. Available from https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:12002E152:EN:HTML
  2. TFEU 2012. Consolidated versions of the Treaty on European Union and the Treaty on the Functioning of the European Union. Official Journal C 326 , 26/10/2012 P. 0001 – 0390 https://eur-lex.europa.eu/legal-content/EN/TXT/HTML/?uri=CELEX:12012E/TXT&from=EN  (Article 168)
  3. The European Commission 2007. White Paper: “Together for Health: A Strategic Approach for the EU 2008-2013”. Available from https://ec.europa.eu/commission/presscorner/detail/en/IP_07_1571
  4. Council of the European Union 2011. Council conclusions on Healthy Ageing across the Lifecycle. Available from https://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/134097.pdf
  5. 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), 500–567. http://dx.doi.org/10.1136/jech.2009.102020
  6. Koivusalo, M., Heinonen, N. & Tynkkynen, L-K. 2021. When actions do not match aspirations – comparison of the European Union policy claims against what has been negotiated for health services, trade and investment. Globalization and Health, 17(1), [98]. https://doi.org/10.1186/s12992-021-00739-8

More:

Council of the European Union, 2006. Council Conclusions on Health in All Policies (HiAP). Available from https://www.consilium.europa.eu/ueDocs/cms_Data/docs/pressData/en/lsa/91929.pdf

Council of the European Union, 2010. Council conclusions on Equity and Health in All Policies: Solidarity in Health. Available from https://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/114994.pdf

Howard, R. & Gunther, S. 2012. Health in All Policies: An EU literature review 2006 – 2011 and interview with key stakeholders. Equity Action. Available from http://chrodis.eu/wp-content/uploads/2015/04/HiAP-Final-Report.pdf

Ministry of Social Affairs and Health 2006. Health in all policies : Prospects and potentials. Ståhl, T., Wismar, M. Ollila, E., Lahtinen, E. & Leppo, K. (Ed.). Available from https://www.euro.who.int/__data/assets/pdf_file/0003/109146/E89260.pdf

Ollila E, Ståhl T, Wismar M, et al. 2006. Health in all policies in the European Union and its member states. Ministry of Social Affairs and Health and European Observatory on Health Systems and Policies. Helsinki.  Available from http://ec.europa.eu/health/ph_projects/2005/action1/docs/2005_1_18_frep_a4_en.pdf.

Pan American Health Organization (PAHO) 2014. Plan of action on health in all policies. Available from https://www.paho.org/hq/dmdocuments/2014/CD53-10-e.pdf

 

HiAP in Finland

The HiAP approach has evolved in Finland over several decades as part of intersectoral or implicit HIAP policies. These include, for example, Nutrition Board with engagement from several Ministries since the 1940s.

A common understanding is that in Finland, HiAP has progressed from a concentration on coordinated activities on high-priority issues to a more general pattern of integrated policy-making that includes intersectoral development of legislation, stands, and programs.1

“The promotion of well-being and health as well as the reduction of inequality will be taken into account in all societal decision-making and incorporated into the activities of all administrative sectors and ministries”, according to the Finnish government’s plan. The intersectoral Advisory Board for Public Health concentrates their work in executing these activities.1

The Finnish experience shows that HiAP as an approach, as a method of working, needs often long-term commitment and vision. National plans legislation and the use of international momentums can foster dedication and a long-term vision. Everyday policymaking has indicated that HiAP is difficult to achieve without sufficient and active health sector personnel with resources, experience, and appropriate awareness of policies in other sectors.2

Finland can be seen as a pioneer in HiAP strategy implementation. Examples of implementation can be found as Health 2015 and the Health for All by the Year 2000 -programmes.3 Also, during EU presidencies Finland has emphasized the intersectoral consideration of health aspects and during the latter presidency the economy of wellbeing was a central theme.4

Sources:

  1. Leppo, K., Ollila, E., Peña, S., Wismar, M & Cook, S. (Ed.). Health in All Policies. Seizing opportunities, implementing policies. Ministry of Social Affairs and Health. Available from https://julkaisut.valtioneuvosto.fi/bitstream/handle/10024/69920/URN_ISBN_978-952-00-3407-8.pdf?sequence=1&isAllowed=y
  2. Ståhl, T. 2018. Health in All Policies: From rhetoric to implementation and evaluation – the Finnish experience. Scandinavian Journal of Public Health, 46, 38–46.  https://doi.org/10.1177/1403494817743895
  3. 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(11), 3–28. https://doi.org/10.1177/1403494812472296
  4. Council of the European Union 2019. The Economy of Well-Being – Executive Summary of the OECD Background Paper on “Creating opportunities for people’s well-being and economic growth”. 1–8. Available from https://data.consilium.europa.eu/doc/document/ST-10414-2019-INIT/en/pdf

More:

Ministry of Social Affairs and Health. Government resolution on the Health 2015 public health programme. Finland: Ministry of Social Affairs and Health, Publications 2001:6. Available from https://julkaisut.valtioneuvosto.fi/bitstream/handle/10024/74588/Julk200106.pdf?sequence=1&isAllowed=y

Ministry of Social Affairs and Health. Health for all by the year 2000. The Finnish national strategy. Finland: Ministry of Social Affairs and Health, 1987. [Not available online]

THL 2019. Health in All Policies. https://thl.fi/en/web/management-of-health-and-wellbeing-promotion/management-of-wellbeing/practices/health-in-all-policies [Read in Nov 2021]

Valtioneuvosto 2021. Hyvinvoinnin, terveyden ja turvallisuuden edistäminen 2030 : Toimeenpanosuunnitelma. Available from https://julkaisut.valtioneuvosto.fi/handle/10024/163021

 

Health Impact Assessment in Wales

Wales in the UK is an example of a country which has used health impact assessment extensively in assessment of health implications of different types of policies. The Wales Health Impact Assessment Support Unit (WHIASU) was founded in 2004 to promote the practice of health impact assessment in Wales. HIA is an interdisciplinary field of public health practice that is used to promote population health and reduce health inequities across sectors such as public health, land use planning, local government, and environmental health.1 It also identifies the health and well-being impacts and addresses health inequalities of policies, plans and proposals, and ‘Health in All Policies’.2

The Welsh Government has set out its commitment to HiAP in ‘Prosperity for All‘3, the national plan for the 5-year term of current National Assembly, to make a difference to wider social and economic factors such as housing, parenting, education, and employment.4

Wales has given a case study report on the Well-being of Future Generations Act5 in a WHO’s case study manual Progressing the Sustainable Development Goals through Health in All Policies6. They present that The Act helps to articulate an understanding of the determinants of health, with good health based on socioeconomic status, early intervention, prevention, enabling physical environments, as well as individual genetics and behavioral choices, not only a result of access to quality health care.

Sources:

  1. Public Health England 2020. A skills and knowledge framework for Health Impact Assessment. https://www.gov.uk/government/case-studies/a-skills-and-knowledge-framework-for-health-impact-assessment [Read in Dec 2021]
  2. Wales Health Impact Assessment Support Unit (WHIASU) https://phwwhocc.co.uk/whiasu/ [Read in Dec 2021]
  3. Welsh Government 2017. Prosperity for All: The national strategy. Taking Wales Forward. Available from https://wcva.cymru/wp-content/uploads/2020/01/Prosperity-for-all.pdf
  4. Welsh Government 2019. A Healthier Wales: our Plan for Health and Social Care. Available from https://gov.wales/sites/default/files/publications/2019-10/a-healthier-wales-action-plan.pdf
  5. Gov.uk 2015. Well-being of Future Generations (Wales) Act 2015. https://www.legislation.gov.uk/anaw/2015/2/contents
  6. WHO 2017. Progressing the Sustainable Development Goals through Health in All Policies: Case studies from around the world. Available from https://cdn.who.int/media/docs/default-source/inaugural-who-partners-forum/progressing-sdg-case-studies-20178560b677-aeef-4dea-a6cc-459258712d41.pdf?sfvrsn=d0096b17_1&download=true

More:

Wales Health Impact Assessment Support Unit (WHIASU) 2019. The Public Health Implications of Brexit in Wales: A Health Impact Assessment Approach. Executive Summary. Available from http://www.wales.nhs.uk/sitesplus/documents/888/PHW_Implications_of_Brexit_ExecSum_Eng.pdf