Editorials

Health in all policies

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4283 (Published 03 July 2013) Cite this as: BMJ 2013;347:f4283
  1. Ilona Kickbusch, director, Global Health Programme
  1. 1Graduate Institute, PO Box 136, CH 1211 Geneva 21, Switzerland
  1. kickbusch{at}bluewin.ch

An approach that accepts that health is not created by ministries of health or healthcare systems

“Health in all policies” has become the catchphrase for taking account of health and equity in the policies of other sectors. Launched last month on the occasion of the eighth International Conference on Health Promotion in Helsinki, a new book intends to provide “practical workable solutions in a range of settings for a range of problems.”1 It aims at a broad audience of policy makers and implementers worldwide, with examples spanning the globe from highly developed welfare states (Finland), to both middle income (Thailand) and low income countries. A welcome feature is the attention given to the global action needed to tackle common problems that span borders—for example, in relation to trade policies. A chapter is included on how development assistance can become more effective through health in all policies.

The book should contribute to a better understanding of how to go about tackling “wicked problems” and complexity in health.2 Eight detailed policy examples—including ones relating to tobacco, alcohol, agriculture and food policies, work, and early child hood development—give a comprehensive overview, with concise short case studies. A special chapter considers the role and responsibilities of the health sector in health in all policies. It shows that ministries of health are not well prepared to play an active role across sectors and handle the conflicts and controversies that come with such a role. Another chapter maps out lessons that can be learnt from the association between environment and health to help achieve health in all policies.

Although this book complements other recent publications well I have some reservations. One is simple and easily corrected: the examples of health in all policies (possibly because they have mainly come from health promotion) tend to neglect the experiences gained in the field of infectious diseases. The lessons learnt from severe acute respiratory syndrome and H7N9 influenza are important examples of how to craft comprehensive policies under conditions of crisis and then prepare for the long term. Some short case studies indicate this, but more would have been useful.

My second reservation is that I would have liked all contributions to have followed more closely the analytical model introduced as a reference point—the Kingdon framework, which identifies three streams of the policy process (recognition of the problem, policies, and politics). This would have enabled better comparisons between policy examples.

My third reservation is more complex. Conceptually I much prefer the term “governance for health and wellbeing” or even more simply “public policies for better health.” Why? In my view the term health in all policies leads to conceptual boundary problems, which also plague this publication. Despite careful editing the authors are not consistent in their use of the term. Health in all policies is used to mean many different things—an approach (which reflects the definition provided), a goal, and a strategy. For example, early child development is described as a “component of health in all policies” and the chapter on “Prioritizing health equity” does not even mention health in all policies; it refers to “action on the social determinants of health.”

The authors state that most documented health in all policies cases are to be found in more developed economies and welfare states; they relate this to limited institutional and regulatory capacity in many developing countries. This is true for challenges such as tobacco or alcohol policies, which require not only public health institutions but regulatory systems and reliable fiscal mechanisms. However, they describe interventions such as the millennium villages project, examples of which can be found throughout the developing world, as “health in all policies-type interventions.” Sometimes the book gives the impression that it is integrating a range of different approaches that involve other sectors into a concept with current currency, rather than extracting the essence of a health in all policies approach from the examples.

The prime minister of Finland’s foreword provides clarity. He points out that all countries, no matter what their level of development, need an explicit political commitment by government to promote wellbeing and health as well as to reduce inequality in decision making. This mirrors the constitution of the World Health Organization, which states that “governments have a responsibility for the health of their people.” It means entering the realm of politics and it links to my fourth reservation. Despite the use of the Kingdon framework, the book’s analysis is weakest in relation to the political determinants of health. Health policy is referred to as a “key battleground” and—for example—the chapter on alcohol states clearly that weak alcohol policies can often be attributed to the central and dominant role of commercial interests in the policy making process. In her speech at the Helsinki conference, Dr Margaret Chan, the director general of WHO, also drew attention to the distortion of public policies by powerful industries. We still require better political analysis of how to win the “health wars.”

Nonetheless, if this new focus means that after decades of medicalising health we accept that most of health is created not by the actions of health ministries or the healthcare system, but by many different policies and by actions in society and everyday life, that surely is progress. If health in all policies is successful as a proxy term to highlight that we need to govern health differently I am 100% on board.

Notes

Cite this as: BMJ 2013;347:f4283

Footnotes

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I was an adviser to the World Health Organization on preparing for the Helsinki conference and helped draft the conference statement.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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