How can we bring public health in all policies? Strategies for healthy societies.

New scenarios are emerging in the European and worldwide context: the ageing of society, the climate changes, the increasing of health inequalities and the financial crisis. In this context, the scientific community and the decision-makers agree on the role of health in all policies (HiAP) strategy in improving the population's health. The HiAP takes into account factors not strictly related to health but with important health consequences. To bring public health in all policies a change is needed, but there are some obstacles to overcome: for instance, the lack of evidence regarding the governance tools and frameworks for HiAP, the difficulty of convincing stakeholders and producing a cultural change in the political positioning of decision-makers. Consequently, it is necessary: i) to implement stronger and responsible decision-support approaches, such as health impact assessment and health technology assessment; ii) to encourage and coordinate all relevant sectors in playing their part in reducing health gaps within the European Union; iii) to strengthen cooperation and make better use of existing networks and existing public health and related institutions. The final aim will be to monitor the impact of the health determinants in order to promote the effective implementation of HiAP approach. Significance for public healthThis paper makes public health professionals aware of the pivotal role that they could play in reducing health inequalities and in helping to overcome the crisis of the European health systems. It discusses how, thanks to a systematic approach based on new instruments like health impact assessment and health technology assessment, and thanks also to a stronger cooperation among stakeholders and policy makers, it is possible to monitor the health determinants and consequently to bring health in all policies.

Introduction

New scenarios are emerging in the European and worldwide context of Public Health since demographic changes, mainly characterized by ageing of society, proceed apace.[1,2] The growth of aged population increases the needs of health systems to identify strategies in order to contain the burden related to chronic diseases, more frequent in older age groups.[3] This need is larger during this period of global and financial crisis that involves politics and societies with their health systems, which in many countries require organizational and structural reforms in order to continue to provide the services expected for citizens.[4,5] Ageing population, rising inequalities and the difficulties associated to the financial crisis require a strong response from governments in order to maintain the health status of their citizens, the deterioration of which may have negative implications in terms of economic productivity and well-being of Nations.[1,2,6] As suggested by S. Jakab, the World Health Organization (WHO) Regional Director for Europe, at times of economic crises it is even more important to take short-term decisions with a long-term perspective in mind: investment in public health, prevention and health promotion should continue to be important issues of the policy agenda of the European governments.[7]

The health status of populations could also be influenced by other factors, such as the increasingly concerns related to the climate changes and to the persistence of inequalities in health among different countries and, within the same Country, among different groups of population.[3] Moreover, it should not be neglected the role of the main risk factors related to lifestyles.[8,9]

The EU, firstly with the Art. 152 of the Treaty of Amsterdam and later with the Art. 168 of the Treaty of Lisbon, pointed out that, in the definition and implementation of all EU policies and activities, a high level of protection of human health must be guaranteed, by complementing the policies implemented at the level of individual countries.[10,11] The importance of this issue was further highlighted when the Finnish Presidency of the EU decided to take the concept of health in all policies as a main theme for the determination of policies during the period of government.[12-15]

Health in all policies (HiAP) is a strategy that aims to improve the health of the population taking into account factors outside the health system but that have important health effects, such as socioeconomic, social and environmental factors affecting life-styles and behaviors.[1] This strategy aims to assist leaders and policy-makers to integrate consideration of health, wellbeing and equity during the development, implementation and evaluation of policies and to identify policy options or specific arrangements to maximize the positive health impact of other policies through interaction with policy-makers and decision-makers in sectors other than health.[11,12,16] The possible areas involved are numerous (Table 1).[16]

Table 1.

Policies sectors with potential effects on population health.

Policies sectors
Economy	Energy
Agriculture and food safety	Transport
Welfare and education	Taxation
Environment	Research

To invest in health and to maintain and to raise the health status of European populations can lead to a virtuous cycle that increase the well-being but also promote stability and economic growth and strengthen the financial sustainability of health systems.[16] Healthier populations, indeed, are more productive, and usually gain higher income. A healthy population is helpful for keeping high levels of wealth and compensating some of the effects of demographic changes mentioned above.[3,15,16] Conversely, the implementation of policies with negative consequences for the health of the population will lead to an extra load for the economy and health systems.

In this respect, the economic argument works, for the health in all policies purpose, as the common language that can be heard and understood across all ministries and sectors and that lends itself to joined-up government actions on health and equity.[16] Thanks to the efforts of the past EU Presidency, the HiAP strategy has been carried out successfully and the considerations expressed through HiAP have now become the key-principles of the European plans related to public health. European Union laws, however, are still more associated with environment and trade sectors, while there are no constraints but only exhortations about health and public health policies. Equity in health, solidarity in health, participation in decision-making, sustainability and health in all policies are principles included in most health policy documents, but less is known about their implementation in practice.[16] Health in all policies is no longer a slogan but, to date, there are still several difficulties in highlighting elements that can indicate an effective and efficient implementation of this strategy into practice of policies introduced at European level.[17,18]

Why is it so hard to bring public health in all policies?

In order to bring public health in all policies a major change of course is needed. A shift of the current situation is a noble aim, but it should take into account that there are some obstacles to reach this goal that are very difficult to overcome.

A first problem is linked to the quality and quantity of evidence-based data. There are, indeed, only few epidemiological studies inquiring the best among a variety of different policies, mainly because policies are closely related to the context in which they are applied and hardly comparable to those implemented in different contexts. Certainly to assess and scientifically demonstrate the effectiveness of the HiAP strategy is then a great challenge, also given that there is not a gold standard to refer for the evaluation of government strategies and tools used to achieve them.[1] Despite the lack in the scientific literature regarding structured governance tools and frameworks for HiAP, it is essential to improve the formulation of policies on the basis of the best scientific evidence available and to make decision-makers aware of the strong linkages among policies, interventions, determinants of health and resulting health outcomes.

In this regard, some recent studies highlighted the impact on health of health policies implemented at a local, National or International level. Gualano et al. analysed the potential impact of smoking ban policies on the number of smokers in Italy,[19] while a UK paper evaluated the correlation between new antibiotic prescribing policies in acute National Health System trust and Clostridium difficile infection rates.[20] A recent American paper investigated how local immigration enforcement policies affected the utilization of health services among immigrants in USA.[21] Moreover, the financial crisis led to the implementation of austerity measures that affected the health of the population, as reported by numerous studies.[22-24]

The bigger issue to face is to involve and convince all the stakeholders, as they often have very different points of view and different ways of understanding the problem.[3,15] In addition, often there is a considerable latency of time between the implementation of a policy and its effects in terms of health outcomes. Indeed, policy integration is easier said than done. Many positive experiences are developed either locally or on specific policy aspects, while it is very difficult to act on extensive policies which have effects on large populations and geographical macro-areas.

Especially for politicians, who usually are in charge only for few years, to invest in health-friendly policies, the effects of which can be seen only in the subsequent electoral periods, may be less attractive than alternative investments with more rapid and visible results in the public eye.[17] Moreover, it should also be considered that often the policies that include measures aimed at preserving or improving the health status do not foresee an increase in costs. The benefits associated to health-related outcomes also tend to be more difficult to measure than immediate costs. It could be also easier to consider at first the costs and benefits of particular or restricted interventions based on the treatment and rehabilitation in comparison with more extensive changes in policies. In this context, new cultural approaches about healthcare and costs, such as Less is More and Best Care at Lower Cost professional movements, are becoming more and more relevant in public opinion and scientific community.[25,26] The implementation of healthy policies could be supported by these health professionals since valuable health benefits with a reduction of costs and of inappropriate diagnosis tests and treatments are expected.

How can we bring public health in all policies?

The easiest way for include health problems into the agenda of decision makers is through emergencies and catastrophes but, even when this happens, the attention tends to be focused on treatment and rehabilitation rather than prevention.[17] It is therefore necessary to find another way to capture the attention of stakeholders and policy-makers and one possible solution is provided by the use of health determinants (Table 2).[27]

Table 2.

Determinants of health.

Category	Determinants
General, socioeconomic and environmental conditions	Agriculture and food production, unemployment, education, water and sanitation, work/environment, health care services, living and working conditions, housing
Social and community networks	Social support, friendship and social relations, social exclusion, stress
Individual lifestyle factors	Feeding, addiction, smoke, physical activity, alcohol
Individual factors	Age, constitutional factors, sex

It is important to conceptualize health through the use of its determinants as they can often be more clearly and quickly influenced by policies and actions in different areas of policy-making, and the results are easily visible in the settings where people live and work.[11,13,15,17] The same determinants typically influence a multitude of health problems, while individual health problems are usually a product of a variety of determinants. This means that policies, interventions and actions outside the health sector can address and influence health determinants more directly than they do with health outcomes. Improvement of health by exploring its determinants can therefore be achieved with greater facility and clarity compared to what is possible using the traditional approach based on health problems.[28,29]

Although the HiAP strategy aims to produce a change, when we start to apply this new approach to another government sector, the primary objective should be to build rather than to change.

The HiAP strategy should add value from a health perspective in order to improve policies or proposals considered. There are multiple ways of interaction among different government sectors.[11,16,17] The two main features include: i) the mutual gains strategy, in which mutual benefits can be found between the objectives of health and those of another area of policies through a simple and clear integration of common actions ii) the single health strategy, in which health is the main objective of cooperation between the parties.[11] The intersectoral actions should be promoted by looking for the best evidence on health determinants, the information related to burden of diseases and the knowledge on the effectiveness of the policies, including impact assessments. The intersectoral collaborations, indeed, depend on the capability of vision and leadership of the central government and on the possibility of making visible the contribution of each sector. Certainly, the health system should encourage other sectors to pursue public health objectives, but this is not always possible since in most governments incentives continue to be aligned with the results of individual departments, more than shared among the different sectors. This approach reduces the effectiveness of public sector in areas like health, since it decreases the possibilities to act on health determinants and on intersectoral and interdependent issues.

The search for evidence and the formulation of policies based on them can not be conducted with the same criteria of epidemiological evidence used for other areas. In Public Health, indeed, many years are often needed before being able to see and evaluate the interventions’ results.

Another field of action includes the search for new partnerships.[11] The first approach is intended to involve decision-makers in all sectors at global, European, national, regional and local levels to make them fully aware of the impact of health policies.[10] If the decision-makers do not respond to the call of public health professionals, other networks can be exploited to bring health into all policies.[30]

Other privileged stakeholders are multi-sectoral policy actors. Furthermore, the role of the media should not be underestimated and new ways of improving scientific competences of journalists should be considered. Responsibility of information and communication units of directors of National Public Health Institutes should be reformulated in order to involve them in the publications of reports and press conferences.[17]

Finally, it is desirable to strengthen the use of responsible decision-support approaches such as Health Impact Assessment (HIA) and Health Technology Assessment (HTA). Interestingly, results of a study performed in order to describe public health research in Northern, Southern and Eastern Europe highlighted the importance of these tools in the public health research agenda.[31] HIA, in particular, is considered one of the more structured approach to put health in all policies.[1,10,11,32] However, this tool should be understood and used more as a mechanism to support decision making than as a mechanism that allows health departments to exercise control over other departments.

Making cross-sectorial work and HIA mandatory is a powerful stimulus for decision-makers and public health professionals to break traditional barriers between them and other sectors.[1] An example is the project Global burden of disease, which proposes a model of comparative risk assessment that should be expanded and linked to policies in order to estimate the burden of disease that could be avoided with the adoption of healthy policies.[18] HIA could be applied similarly by Public Health professionals in order to evaluate the health consequences of the omission or non-activation of certain policies.

The final considerations of this type of HIA could be transformed into indicators of burden of disease avoidable through the policy, presenting a large variety of outcomes such as mortality, hospitalizations, cases of disease that could be affected by a particular policy implemented.

Conclusions

In conclusion, societies have to face a new challenge with the help of professionals in the field of Public Health. The demographic changes and the economic crisis urgently require the implementation of measures that are effective in increasing populations’ health and in avoiding an increase of public expenditure. The most concrete possibility of reaching this goal can be to act in the context of the determinants of health. This action is made possible through the effective application of the strategy HiAP into policies introduced by the EU and through the evaluation of methods aimed at complementing and improving the already existing policies. Moreover, the size of health gaps (defined as differences in premature mortality, morbidity and disability prevalence between and within Member States) within the EU is still huge and it is inconsistent with EU core values such as solidarity, equity and universality. As suggested by the Council of European Union on Brussels (November, the 17th 2011), Health in all policies approach with an equity focus should be used in specific policy areas and coordinated activities that have the greatest health impact contributing to reducing the persisting health gaps. The needs to promote the effective implementation of HiAP approach, to encourage and coordinate all relevant sectors in playing their part in reducing health gaps within the EU, to strengthen cooperation and make better use of existing networks and public health and related institutions in order to monitor the impact of the health determinants clearly emerge.

Further studies are strongly required, in order to build a base of robust scientific evidence demonstrating the effectiveness of existing policies to obtain a starting point, the most widely shared by EU Member States, for the creation of a structured model of policy-making designed to render existing laws more healthy.