The challenge of implementation

The initial report on HiAP explored potential mechanisms to implement the strategy, including health impact assessments, intersectoral cooperative mechanisms, formal consultations in drafting of legislation, national policy reports and parliamentary scrutiny.1 Health impact assessments (HIA) have traditionally been focused more at project than policy level, and, as they are usually contracted out to outside consultants, the role of HIA in assessing policy implications tends to face further administrative hurdles. Other potential avenues include policy reviews, assessment of policy implications or audits.

The implementation challenge for HiAP resides in various factors, but three key factors have been identified. First, the compatibility of sectors with the main interests, second, the scope of which sectors can address improvement of health determinants on their own, and, third, in terms of costs that accrue from taking health into account.3 Ollila6 has defined at least four different strategies on the basis of earlier literature, consisting of 1. health strategy, where health objectives are maintained at the core of the exercise, 2. the win‑win strategy or mutual interest strategy, which is geared to find policies and actions that benefit all parties, 3. the cooperation strategy, which emphasises systemic cooperation and making expertise available in asking what the health sector could do for the others in helping them to achieve their goals, and 4. the damage limitation strategy, where potential negative health effects identified in policy proposals deriving from outside the health sector are being addressed.

In this context it is important to ask to what extent different strategies are necessary for different sectors and their relationship with health considerations and concerns. The present interest in focus and methods for implementation of HiAP may also differ not only in terms of substantive issues and sectors, but also in relation to level of governance. We may also be more aware of community and local assessment and project level use of HIA,7 but have relatively little knowledge – or thinking – on how to preserve regulatory policy and resource space so as to influence social determinants of health at the level of national or supranational policies.8 9 It has also been argued that an appropriate HIA is policy-specific, time-specific and place-specific, reflecting the decision-making model of the policy at stake.10 Particular means and mechanisms that are of fundamental relevance at local level may also serve a different purpose at European level. Participation of those that will be affected by the project or planning decision is an important aspect of HIAs, on the other hand stakeholders of corporate representatives in early stages of legislative and policy processes are also of importance for European-level economic actors and their interest in impact assessments.11

Are we seeking appropriate means for appropriate policies and level of action?

In reporting on HiAP, we tend to seek assessment on what works rather than what should be done and how to get there. As result of this, we may gain a bias towards sectors and areas where there are more mutual interests and ‘easily picked low hanging fruits’, and focus more on cooperative and joint activities on the basis of mutual interest or mechanisms more easily implementable as administrative planning devices. The means and mechanisms used in intersectoral work within administration and planning are also likely to be different from those that would strengthen accountability as part of political decision-making and approval mechanisms of policies. The scope for disagreement in intersectoral administration is usually limited as it can bite back in difficulties in consultations when favours need to be returned. It is also more difficult for Ministries with less political weight, which is often the case for Ministries of Health, to engage with policies of those with higher prestige. In areas where mutual cooperation is likely to fail, the stakes of political accountability rise. Yet there is little, if any, analysis of how to enhance the political legitimacy and accountability to take health into account in policies, where partners are reluctant or dismissive to take on board health considerations or those that relate to functioning and capacities of health systems. This is not merely a problem of national policies, but also European-level policies, further complicated by relations within health policies between commission and member states.

It is clear and is recognised that there is a need for research to make the case for health in all policies.12 However, we may also need further focus not only on making the case with respect to health implications, but also understanding better impacts of other policies on the scope and nature of public policies that relate to health. We will also need more capacities in policy analysis and use of mixed and qualitative methods taking into account a variety of changes and perspectives so as to understand better how and what kind of evidence will matter. On the other hand, it is reasonable to assume that success or lack of implementation of HiAP is unlikely to be based merely on evidence, but is also dependent on gaining voice, legitimacy and presence as part of governance and accountability of policies. In this context we need to recognise that HiAP, to a large extent, remains more rhetoric than action,6 but also that to get to the rhetorics has to be seen as part of action. We need HiAP to be an aim so as to legitimate calls and demands for measures, hearings, reports and follow-up on how this has been tackled.

A recent study for the Dutch Council for Public Health and Healthcare explored issues with respect to HiAP as a governance tool with six case studies, and concluded that making HIA and intersectoral work mandatory gave powerful levers for public health decision-makers and practitioners to break the ‘silo’ between them and other sectors. The capacity to use the window of opportunity in doing this as part of review or change of legislation was judged to be a winning strategy.13 However, even in this study on governance, the focus does not fully cover issues that relate to political decision-making and the basis for ensuring that crucial health concerns are discussed and weighed as part of decision-making processes at political level. This would require focus on transparency with respect to the ways in which health considerations have been considered or not, or focus on how these could better be included not only as part of administrative and planning procedures, but also discussions and debates concerning political decision-making on policies relevant to health. The benefit of HiAP in comparison to HIAs as such is that it is not necessarily bound or limited to a single measure such as HIA or to civil service practices across different sectors, but can extend and be applied in the context of political decision-making and accountability.

The state of HiAP in Europe

The European Union (EU) (Council) Employment, Social Policy, Health and Consumer Affairs Council's conclusions on HiAP reflect the fact that the passage of this approach to the European policy agenda has been neither expeditious nor actively sought by the European Commission (EC) as it refers to the ‘long-dated’ commitment of the Council.2 As Council is not able to make initiatives, the issue has been in the hands of EC for a long time, which despite Council encouragement since the early 1990s has not acted swiftly on the matter. There are thus valid concerns over the extent to which the EC will further this approach. Furthermore, there are also new concerns and tensions, which relate to European Court of Justice judgements as well as implications of market freedoms, internal market regulations and even Commission proposal concerning directive on cross-border care to financial sustainability, organisation and regulatory policy space within national health systems.

European policies and policy approaches tend to remain articulated as comparative case studies in different member states. This is at times helpful for mutual learning, but tends to ignore the emerging supranational level of governance within the EU, which has become strengthened also in the context of the Lisbon Treaty.5 European influence is legitimated on the basis of treaties and substantive law of the EU.14 15 The EU has, on the other hand, had an expanding influence on national health policies as a result of requirements of EU law and the broadening of European-level focus from public health to health services.5 16 17

Thus, HiAP in the context of EU policies is not merely about extending health promotion activities to other sectors, but also about how to ensure that health policies can be designed and implemented on the basis of health policy priorities, rather than, for example, commercial policy priorities. This has relevance also to the ways in which we interpret and seek to implement the HiAP approach. Strategies in the area are often based on thinking from the perspective of health promotion efforts, not recognising the need to secure policy space for appropriate regulatory scope and cost-containment in health systems, and a high level of health protection poses a real challenge in European policies, as other policies have become important in defining policies and scope of health regulation. The issue is not only health in all policies, but also health in health policies.

Initial work on HIA and other means to integrate health in other policies was first traced in an overview of means to enhance healthy public policies in Europe in the late 1990s.18 Further Commission-supported projects have provided evidence on the adequacy of methods in assessing health impacts of policies as well as the state of HIA in member states.19 20 Attention had been drawn to the lack of structures and mechanisms to address intersectoral public health issues in the enlarged EU.21 The slowly moving processes through project funding by the Directorate responsible for Health (DG SANCO) were overtaken in the EU by the overall process of impact assessments under which health also later became included. While the good news is that there exists now structure and means for impact assessment that applies to all new key EU policies, the bad news is that there are serious concerns over the ways in which this affects public health aims and priorities.

Concerns with respect to the ways in which impact assessments were tied with the policies driven by the internal market ‘better regulation’ process and the relative power positions between economic and health considerations were raised in 2006, when the HiAP approach was being introduced.4 Particularly worrying is the research on the reported influence of corporate interests and the tobacco industry in the process, in seeking a form of impact assessment that overemphasises economic impacts of measures and gives less value for assessing health impacts.11 The limited consideration of health in impact assessments is another concern. An internal review by the UK's National Heart Forum showed that, in 2005 and 2006, 73 of 137 impact assessments undertaken by the EC did not mention health in relation to health systems or public health.22 Another analysis on impact assessments made in 2006 found that health did not play a prominent part in these, and impact assessments made by the Directorate-General (DG) Trade, Enterprise, Taxation and Customs and Development did not include mention of human health, public health or health systems in their impact assessments, indicating that problems were framed according to the perspective of the DG, who carried out the impact assessment.23 Although this does not imply that there could not be further scope for health impact assessment as a means to enhance HiAP at European level, it is necessary to take seriously the politics that relate to the undertaking of impact assessments as part of EU work, and to recognise that in the current context impact assessment can not only be means to enhance, but also to undermine public health aims.

The need to consider impact assessments in the EU as political means and basis for exchange has been brought up in analysis of the purposes for impact assessments.24 As assessment of environmental and social impacts seems to have similar problems to HIA,25 26 this could provide support for efforts towards further revision of impact assessments or seeking another avenue closer to political decision-making taking into account the context of European policy-making and relying more on capacities from health, environmental and social issues than those within which impact assessment takes place. Concerns have been raised also with respect to the limits and pitfalls of HIA as a means to enhance recognition of societal determinants of health.27 This implies that the public health community may need to reconsider expectations from the use of HIAs within the current context and structure of EU policies. Furthermore, recognition of current pitfalls in HIA process and governance in the EU is important if actions with respect to reduction of health inequalities seek HIAs as a means towards this end. Finally, it is important that if governments are interested in using HIA more at national level, they recognise problems with HIA under impact assessment process at European level.