4 - Next steps: making Health for All Policies

Summary

This finally introductory chapter emphasises the goal of the book: Rather than reinvent the idea of HiAP, we propose that it simply needs to be expanded. Instead of just offering the one-directional relationship that HiAP proposes (other sectors è health), an expansion of thought is required to make this offer two-dimensional. Health for all policies posits that other sectors help the health sector, and that the health sector helps other sectors. This new relationship highlights what health can do for other sectors while simultaneously attaining co-benefits for its own sector.

4.1 Introduction

The case for Health for All Policies is not just that other policies can affect health – it is that health can contribute to the achievement of a wide range of policy goals, from avoiding catastrophic costs that push people into poverty, to reducing gender inequalities in work, to reducing climate change and enhancing urban environments.

This is a summons to generalist policymakers and governments not to underestimate the impact of health expenditures on their economies and societies. Better health can lead to better education, work and equality, among many other things, while health expenditure, intelligently used, can lead to scientific and industrial development, workforce investment, and more liveable and sustainable cities. Investment in health and better health outcomes clearly contribute to economic growth. Understanding the impact of better health across the SDGs can show the importance of a focus on better health outcomes.

This is also a summons to health sector policymakers. The policy and scholarly literature on Health in All Policies is vast. We found in our research that there was far less attention paid to what health policies and organizations could do for others – to the ways in which health policies, focused on health outcomes, can contribute to avoidable problems ranging from global heating to unsustainable cities to inequalities in the workforce. Health for All Policies does not just rebrand Health in All Policies with a new look; it also calls on policymakers, and people across the health sector, to do what they have called on others to do and think about the impact of their decisions on the rest of society – which as we all know, will eventually also affect health.

4.2 Understanding co-benefits

This book’s substantive chapters present variations on a methodological approach that could be used and improved in scholarly and policy research. The book identified, in Chapter 1, two causal mechanisms connecting health policies and systems with achieving other goals. One is through the actions of health policies and systems directly; the other is through improved health status. The two approaches require different kinds of policy analysis to develop. Still, in both cases there is ample scope to create precise and persuasive policy analysis that can identify areas where health policy and health can help to achieve other goals.

In the substantive chapters of this book, we focus on how health policies and systems can contribute to the other SDGs, in their capacities as employers, research-intensive industries, large owners of infrastructure, expensive services, businesses, and more. This is an often under-appreciated area of study. For all that health policy analysts and advocates, under the flag of HiAP, called for health to be a focus of other policy areas, health policies and systems did not always contribute what they could. The low-hanging fruit that is so easy to see in other sectors, the walkable streets unbuilt or the healthy school food unserved, was replicated in the city-centre hospitals unbuilt or the industrial food purchases of the hospital. In other words, part of Health for All Policies means developing the policy analysis tools to understand the impact of health infrastructure and services on climate change and cities, or the impact of the health care sector’s employment decisions on jobs and inequalities. The COVID-19 pandemic briefly made public health policy exceptionally important. It also showed the importance of integrating broader public policy with health in a way that went far beyond pre-crisis concepts of intersectoral action (Greer et al., 2021a; Jarman, 2021).

Researching this topic would follow the model of the substantive chapters. Starting with knowledge of the specific topic area, it would involve identifying the key mechanisms through which health policies and systems affect other SDGs and the policy tools available which could change that impact for the better. It would then be subject to filtering what is possible, not just in the abstract but in the concrete political situation and governance arrangements. As a side benefit, if this identified problems (for example in government contracting rules or accountability arrangements) which prevented health policies and systems from contributing to broader win-win outcomes, that would be an insight of use for reforming governance in a way that otherwise might not emerge.

A second approach, equally important, would be to develop and improve methods for estimating the impact on other SDGs of improved health status. This would build on existing literature, discussed in Chapters 1 and 2, that finds a positive relationship between improved health and education, employment, economic growth and other SDG goals. The possibilities for finding and using data are endless, and the consequences of developing and diffusing tools and estimates of the impact of improved health on other policy areas could be dramatic.

In both, it is important to emphasize the importance of reducing health inequalities. Many SDGs contain specific discussions of the importance of equity, and some are specifically about it. The need to address inequalities in order to address overall social goods is a basic mathematical as well as an ethical proposition. One way to shift an average result is to try to shift the median person in the distribution; another is to look and see if something is producing fat tails of people who are suffering needlessly. If a health inequality, such as failing to address any single population’s needs, is shaping overall health outcomes, then it might be an efficient way to improve health for the whole population as well as an imperative to redress inequalities.

It is also important to underline the role of politics and governance analysis in both the development of policies and the development of tools for policy analysis. The challenges of intersectoral governance in the case of HiAP are well known. Still, there is scope to reframe the question as: what political conditions and governance arrangements enable H4AP, through the identification and enactment of win-win, positive-sum policies? In terms of broader governance, are there specific policies in areas such as legislative organization, budgeting processes and rules, or legal accountability, which impede win-win solutions and how might they be changed?

4.3 Attaining co-benefits: politics

Co-benefits are, in principle, a way to turn zero-sum conversations about budgets and political priority into a focus on win-win solutions. The allocation of money, authority, credit and blame will have to be negotiated over and over again between policymakers and other groups. Still, the potential benefits across government can be dramatic. Nonetheless, there will be resistance in different contexts.

One of the ways in which political processes can be redirected to identify co-benefits is to mainstream such thinking in the various units of government engaged in policy analysis and evaluation. These units, typically found across government and most powerful in units associated with finance ministries and heads of government, can often shape government action with superficially technical discussions of cost-benefit, cost-effectiveness and other kinds of evaluations. While understanding the mixture of economics, accounting and modelling that these practitioners do can be a challenge, it is often crucial to those who would advocate for a policy change built on the subtler and more interconnected logic of co-benefits. One approach is to extend the diversity and complexity of their models, by, for example, paying more attention to the externalities of a policy (consider, once again, the impact on other SDGs of a new-build hospital on the edge of the city with poor public transport). Basic methods such as attributing quality-adjusted life years (QALYs) can, in principle, be applied to the impact of policies far beyond health technology. Another is to consider additional endpoints, such as wellness, happiness, human development or even a conceptually simple focus on lives saved by different interventions.

The European Union, in particular, has declared that the SDGs are the goals of its Semester, replacing its older 2020 goals (Greer & Brooks, 2020; Greer et al., 2022; Verdun & Vanhercke, 2022). This decision by the EU is not just an impressive change from the Semester’s early and intense focus on deficits. It also creates a potential opportunity to use the Semester, a large and increasingly sophisticated process, to expand the range of commonly used analytic techniques that governments use in order to show how policies attain more than one SDG through co-benefits.

The politics of knowledge are important, and we might be surprised how many policies look different and can be evaluated differently if we have better accepted ways of analysing co-benefits. But there are also straightforward politics. Most existing activities of government come with constituencies that have strong interests in something like a better-funded version of the status quo. From professions to pharmaceutical companies, health is no exception at all to this rule. But the political hope of a logic of co-benefits is that it can create different coalitions – by, for example, changing the scope of conflict surrounding decisions about health infrastructure, employment, research and other topics (Hacker & Pierson, 2014; Schattschneider, 1935).

4.4 Implementing and sustaining co-benefits: governance

While every situation and place is different, there are consistent problems in implementing and sustaining policy change, problems which are made worse in intersectoral contexts where concepts, priorities, interests and all manner of organizational, legal and infrastructural legacies shape what can be done. Part of the logic of co-benefits is that it can create or reform coalitions, by, for example, showing how the size and type of resources invested in the health sector can attain other goals through better health or through health policies and systems. Nonetheless, it is important to focus on the governance that can lead organizations to actually implement new priorities and keep implementing them even after the politics have changed. How do we construct, in short, governance that supports Health for All Policies?

Table 3.1 lists a number of the key ways policymakers have tried to support intersectoral governance, including budgets, appointments, plans and laws. Each has its place, but it is often important to focus on ways to entrench policies through legislation and budgetary processes, as well as review and evaluation systems, which make clear their value and are hard to change.

4.5 Conclusion: key takeaways

The Health in All Policies (HiAP) approach was often alive to the political and practical advantages of positive-sum, win-win policies but often was read as emphasizing a one-directional relationship between health and other sectors (transport, environment, education and health) to produce positive health outcomes. Examples of this include better street designs to promote the use of bicycles, and more nutritious foods in schools leading to fewer health problems. The result was two significant problems with the HiAP approach. The first is that it has proven difficult to engage other sectors as they are likely convinced that health ministers expect other sectors to fix their problems. The second problem is that many sectors believe health is not their business (de Leeuw, 2017).

While the second problem was partially solved during the COVID-19 pandemic in which sectors were forced to work together in the name of health, the issue of sustainability remains. How can we get sectors to work together over time (Greer & Lillvis, 2014)? We argue that creating co-benefits for multiple sectors across shared goals can be the answer. Thus, rather than reinvent the idea of HiAP, we propose that it simply needs to be expanded. Instead of just offering the one-directional relationship that HiAP proposes (other sectors health), an expansion of thought is required to make this offer two-dimensional. Health for All Policies posits that other sectors help the health sector, and that the health sector helps other sectors. This new relationship highlights what health can do for other sectors while simultaneously attaining co-benefits for its own sector.

The takeaways from this project can be summarized this way:

• Move from Health in All Policies to Health for All Policies. This proposes keeping the already existing relationship between health and other sectors and the health co-benefits they produce and adding a new relationship that puts other sectors at the forefront and highlights what they can do for health whilst simultaneously attaining co-benefits for their sectors.

• There are three reasons to focus on co-benefits if we are to achieve the SDG target goals: co-benefits for other sectors of health policy and investment can open up new policy opportunities; co-benefits are likely to be necessary if we are to attain key goals; and interacting sources of health and health inequalities can be better understood.

• Achieving co-benefits places the focus on politics. Without the cooperation of political actors, proposals remain ideas instead of becoming concrete actions or policies. Often, when the focus is placed on politics we are faced with a political problem, namely that the government does not agree with itself.

• Intersectoral governance structures are important to consider when attempting to address and achieve the targets laid out within the SDGs. By aligning both health and non-health objectives, co-benefits can be achieved. This benefits not only the health sector, but also any other sector (environment, education, transportation, etc.) working in unison with the health sector.

The time is right to reconsider intersectoral – and sectoral – action for broad goals. COVID-19 showed that governments worldwide, poor and rich, are capable of extraordinary policy and integration feats (Greer et al., 2021a). It showed the interconnections of many policy sectors and ruthlessly exposed weaknesses of all kinds (Sagan et al., 2021). It created interest in future work to build the resilience of health systems and societies (Hynes et al., 2020; McKee, 2021; Williamson et al., 2022). And, in terms of the SDGs, it also did tremendous damage. The impact of the pandemic on health, directly and indirectly, was a disaster for much of the world (WHO, 2022). The interaction of the pandemic and various social, economic and policy responses reversed the already faltering progress the world was making on many other SDGs (United Nations, Sustainable Development Goals Report 2021). A pre-pandemic debate about whether we were making sufficient progress has turned into a post-pandemic debate about whether we can ever make up the regress and start to make gains again. Without Health for All Policies, the answer might well be no.