Lessons from the case studies

Claire Greszczuk, Tim Elwell-Sutton and Jo Bibby

The nine case studies offer valuable insights into the practicalities of delivering a health in all policies approach in different contexts and sectors, and at different levels of government. Each example offers ideas and learning points that policymakers and practitioners may draw on and adapt to design and deliver initiatives in their areas.

The collection demonstrates several critical ingredients for implementing and sustaining a health in all policies approach:

  • Leadership, politics and events that align to create policy windows. For example, Paris saw a step change in action on air pollution when mayor Anne Hidalgo took office on a pledge to rid the city of diesel vehicles. Find out how Mayor Hidalgo led a package of ambitious policies to improve the air quality in Paris on page 24.
  • Cross-sector and cross-government participation. For example, Norway’s approach to making health a cross-sector responsibility was through the Public Health Act 2012, which placed a duty on government departments at national, regional and local levels to incorporate health in policymaking and practice. Find out more on page 54.
  • Framing the issue to secure stakeholders’ support. The case study on US action on prisoner reoffending illustrates how powerful public health messages can emerge in unexpected ways that capture widespread support for change. Read more about how President George W Bush promoted support for prisoners on page 37.
  • Community involvement. For instance, extensive engagement with local stakeholders, including city residents, enabled the Swedish city of Malmö’s Commission for a Socially Sustainable Malmö to: identify the issues that mattered most to local communities, implement meaningful and realistic change, and bring people along from the start. Learn about some of the innovative actions taken in Malmö on page 15.

However, the initiatives did not always deliver the ambitions intended. The case studies highlight a multitude of complex barriers to delivering and sustaining cross-sectoral partnerships for health, which may explain why progress can be slow. The following challenges were common to many of the initiatives:

  • Lack of alignment in incentives. Failure to adequately reward performance (which is especially important in situations where costs are incurred by one department and the benefits fall elsewhere), or a failure to frame goals in ways that engage non-health stakeholders, can prevent stakeholders participating. For example, although Norway’s Public Health Act required all government departments to consider health and health equity, the legislation alone was insufficient to embed health in all policies since stakeholders did not see how it would benefit their department. Continual influencing by the public health community was needed to garner support and explain how a health in all policies approach could deliver co-benefits to non-health sectors. Read more on page 54.
  • Competing priorities. These can prevent collaboration and mean good intentions fall short when priorities change. For example, five years after Pennsylvania’s Fresh Food Financing Initiative was launched, the global financial crisis hit and the state could no longer fund the programme. Read more about what the programme achieved, and its legacy, on page 45.
  • Maintaining the focus on health equity. Health equity can often get lost when health in all policies approaches are planned and implemented. This may be due to a lack of awareness of the difference between improving health and improving health equity, a lack of relevant data, or simply because not enough people experiencing inequalities have been involved in the process. For example, although South Australia’s social inclusion initiative had many successes, health inequalities had not changed 10 years on. Read more on page 30.
  • Inability to make long-term investments. On page 15, the example of Malmö’s Commission to embed social sustainability across the city illustrates the way in which inflexible annual budgeting cycles can present a barrier to long-term investment.
  • Limited evaluation. Failure to build in comprehensive evaluations, or a lack of suitable methods for assessing policy and programmes’ complex impacts, means initiatives may not generate learning for the future. For example, although the Healthy Canada by Design project (page 63) was rigorously evaluated over three years, this may have been too short a time frame to measure its health outcomes, especially since the urban planning process typically takes five to 10 years. Further, it was difficult to design an evaluation that would capture the project’s complex impacts in a way that could be attributed to the initiative.

Recent trends suggest the UK faces some formidable challenges in improving the length and quality of people’s lives. Many of the major public health issues of our times – rising child obesity, increasing mental health problems, and a growing number of environmental crises – arise from complex systems involving different sectors. Creating healthy lives, therefore, not only needs action outside the health system, but also an approach that goes beyond disease-specific strategies. Broad-based action is needed to improve the social, environmental, economic and commercial conditions in which people live. Is a health in all policies approach the right way to achieve that?

For some, the health in all policies concept has not lived up to its early promise. As these case studies show, there are many challenges and barriers to the approach but, when the right ingredients are present, such strategies can deliver tangible value for people’s long-term health. There is already visible leadership and innovative cross-sectoral working within the UK, in local authorities and at national levels, notably in Scotland and Wales. All these places, both at home and abroad, provide inspiration and insights that can support people and places everywhere to innovate, test and spread new approaches to creating healthy lives.

The Health Foundation’s Healthy Lives strategy emphasises the importance of cross-sector and whole government action. It argues that the good health of a nation needs to be viewed as an asset to society and the economy – one that should attract long-term investment that maintains and improves people’s health and addresses health inequalities. This will require all policy- and decision-makers to consider the value – or at times cost – of their actions to people’s health. Ultimately it will require government to be more accountable for the impact of policies on health, with health and wellbeing measures set on an equal footing to economic outcomes such as GDP. In short, health should be viewed as a shared value across government and beyond.

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