The World Health Organization’s European office has just published a very interesting book on Governance for Health in the 21st Century. It begins from a social determinants and broad view of health and well-being, and provides a very comprehensive review of the kinds of governing and decision-making frameworks and approaches that are necessary to enhance population health. Among its directions for ‘smart governance’ of health are more whole-of-government and whole-of-society integrated models; correspondingly collaborative and community-engaged approaches; a strategic mix of policy levers, from regulation through persuasion to enabling; an increasing role for expert agencies and more networked approaches to policy development; and elaboration of adaptive and forward-looking policy development that can address complex and ‘wicked’ challenges.
Among its topics is one that has attracted increasing attention: Health in All Policies. This simply means that because health is shaped by so many determinants well beyond health care, understanding the implications for health must be embedded in policy development in spheres across governments; from transportation and urban planning, through environmental regulation, to fiscal and employment policy, and that coordinated action across governments is critical to address the underlying social and economic determinants of health. Ensuring this more joined-up approach really does have an impact on government policy requires two key directions not often mentioned in the academic literature.
First of all, HiAP approaches need to well aligned with the ways governments actually work. This would need to include:
- participation from departments and agencies across government needs to be required through legislative, regulatory or policy directives, such as in Quebec;
- enabled through effective and user-friendly processes, forums to share experience and collaboratively analyze the health implications of policy directions and programs, and technical support from central agencies;
- facilitated through proven tools such as Health Impact Assessment or Health Equity Impact Assessment;
- requirements need to be matched with explicit deliverables and targets for departments and agencies: e.g. various British national plans to address health inequities have included deliverables from many non-health departments;
- plus transparent reporting on progress against these targets;
- and matched with incentives, both organizational, so that funding allocations for relevant departments are tied to delivering on wider social determinants and health equity expectations; and personal, so that the performance-related pay of senior government officials is tied to delivering on these cross-sectoral equity expectations every bit as much as their more specific departmental mandates.
HiAP needs to ensure not just better policy coordination and embedding population health principles across governments, but it needs to drive very different kinds of progressive policies. So, policies need to reducing systemic social and economic inequality. For example, fiscal policy needs to look at the revenue side, and not just simplistically fixate on program cuts that will disproportionately affect the already vulnerable; minimum wage, unemployment insurance, training, labour market regulation, health and safety policies, social assistance and so many other areas of social and employment policy need to address precarious work — and be willing to face employer resistance. All of this means that policy needs to address the entrenched interests of some very powerful forces in contemporary society.
Difficult and complex — certainly. But essential.