Navigating Degrees of Collaboration: A Proposed Framework for Identifying and Implementing Health in All Policies.

Author:Huang, Tiffany J.
Position:SPECIAL REPORT - Report


As environmental health practice increasingly shifts from a regulatory focus toward community-based approaches to prevention, more jurisdictions are adopting a Health in All Policies (HiAP) approach. While the literature provides multiple definitions of HiAP, we use the definition provided by the World Health Organization (WHO), which encompasses outcomes, purpose, and an ultimate goal: HiAP is "an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity" (WHO, 2014). This practice uses a systems approach to ensure that policy making has neutral or beneficial health impacts.

Environmental health professionals routinely work with other sectors, so HiAP is particularly relevant as a process that can promote prevention-focused policies across sectors to improve health outcomes. As such, environmental health professionals have played a key role in developing HiAP initiatives. For example, the District of Columbia's HiAP taskforce is cochaired by the city's Department of Health and Department of the Environment (National Association of County and City Health Officials [NACCHO], 2017). At the state level, California's HiAP Task Force works on a number of environmental health initiatives, including healthy housing, air quality, climate change, and green spaces (California Strategic Growth Council, 2018).

Identifying the Need for a Unifying Framework

In 2015, the National Association of County and City Health Officials (NACCHO) undertook a review of current HiAP efforts across the country, focusing specifically on local governmental efforts. The authors of this evaluation updated an earlier literature review on HiAP (Gase, Pennotti, & Smith, 2013); interviewed state and local practitioners who were implementing HiAP; and explored the themes, commonalities, and differences that distinguished their approaches (NACCHO, 2017). Two trends emerged from this work.

First, interest in HiAP has exploded in recent years. Though the concept of "intersectoral collaboration for health" dates back to the 1978 WHO Declaration of Alma-Ata, HiAP has truly proliferated both nationally and internationally in the past 15 years (Rudolph, Caplan, Ben-Moshe, & Dillon, 2013). As an illustration of this recent growth, PubMed search results over time for "health in all policies" (quotations included) reveal only one article on the topic published in 2007, compared with 29 results in 2016. Nevertheless, research efforts remain relatively nascent.

The second trend is a lack of consistency in defining HiAP, with researchers and practitioners offering varying descriptions of HiAP and similar concepts. No single framework has emerged as the gold standard for implementation, in part due to the fragmented nature of the public health system within the U.S. This inconsistency is not unique to HiAP work. The public health field often deals with complex social problems that require cross-sector collaboration and multidisciplinary approaches to solve. Policy stakeholders often use different terms for different audiences; they also sometimes prefer abstract language that is more inclusive of competing interests and values (Hendriks et al., 2014). For example, health equity practitioners and researchers often preface their work by defining terms, such as "equity," "equality," "inequity," and "disparity," in order to clarify for the reader how exactly they use each term.

Unfortunately, inconsistency can hamper efforts at implementation, standardization, replication, and evaluation among partners who disagree with or simply misunderstand each other. For example, inconsistency can lead to miscommunication if one party in a collaboration believes that "health equity" means ensuring equal access to healthcare services, while another party believes that it means working on social determinants of health. Successful collaborations require that all parties understand each other's roles and expectations, including a common understanding of underlying frameworks and nomenclature.

Inconsistency also hinders evaluation efforts. If practitioners use the same term to describe a range of activities, evaluators cannot accurately compare strategies and their outcomes. Evaluating HiAP's effectiveness thus becomes a "necessarily complex affair" (De Leeuw & Peters, 2015). For environmental health practitioners, rigorous evaluation is needed to provide guidance on best practices and implementation.

In response to these trends in recent HiAP work, we developed a framework for understanding the variety of terms and methods that are currently being used to describe HiAP efforts. By identifying these approaches, we provide environmental health practitioners with a common language for working with partners, as well as for planning, implementation, and evaluation.

Uniting the Elements of Health in All Policies

Previous authors have catalogued a variety of HiAP terms. For example, Gase and coauthors (2013) identified approaches similar to HiAP that they defined as "not explicitly" HiAP, but rather approaches that "could be considered a part of a HiAP 'toolkit.'" These approaches included "healthy public policy," "intersectoral action on health," "social determinants of health," and "cross-agency/ cross-sector efforts." Freiler and coauthors (2013) propose a glossary in which HiAP implementation is framed as "a special case" of intersectoral action.

Similarly, Kickbusch and Buckett (2010) describe HiAP as part of a set of horizontal governance approaches that emerged in waves, beginning in the late 1970s with "intersectoral action," then moving to "healthy public policy," and finally evolving as "HiAP." Hendriks and coauthors (2014) summarize "definitions and goals of integrated public health policies or related notions with a similar content, as proposed in the literature." These notions include "Health in All Policies," "multisector policy," "integrated health policy," and "whole of government."

A Spectrum of Collaboration

In the HiAP-related approaches that are described in the literature, collaboration emerges as a unifying theme, with cross-sector relationship building serving as a key element of HiAP practice (Association of State and Territorial Health Officials [ASTHO], 2013; NACCHO, 2014; Rudolph et al., 2013). In one guide, Rudolph and coauthors (2013) identify a "continuum of joint working relationships" that ranges from simple "information exchange" to the more comprehensive "collaboration," which "invites shared responsibility in decision making and implementation." This spectrum recalls Himmelman's (2002) continuum of strategies for working together, which ranges from "networking" to "collaboration." Table 1 shows the differences and overlaps in the definitions from these two sources.

A Model for Conceptualizing Health in All Policies

Taking the above...

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