Health in All Policies (HiAP), School Health & A Commitment to True Partnerships

(From the ISHN Member information service)  An article in Issue #1, 2015 of Public Health Reports discusses how governments can implement a Health in All Policies (HiAP) approach to inter-sectorial cooperation by using their legislative, regulatory leadership and funding levers. The article makes several practical suggestions on how governments can use the law to prescribe, authorize, structure and fund inter-sectorial cooperation. The article provide several state and local agency examples for each of these suggestions. Most of these cited legally required cooperative actions in the article are focused on responses to specific health issues rather than long-term inter-ministry or intra-ministry cooperation or long term approaches such as school health programs. However, the article can be used as a litmus test of government commitments to requiring and supporting their health ministries to work within other ministries and sectors who deliver their programs in settings such as schools, municipalities, workplaces etc. 
In this ISHN comment, we extract the suggestions from the article to determine if there is a commitment to the inter-sectorial approach that we call school health promotion. 
The article reviews the HiAP approach: "The U.S. Centers for Disease Control and Prevention, Institute of Medicine (IOM), European Union, and World Health Organization all recognize the potential of HiAP to address the social determinantsof health, and through them, upstream contributions to morbidity and mortality.Sometimes called “healthy public policy”14 or described as a component of “horizontal government,” “joint-up government,” or “whole-of-government,”15 HiAP is an approach that integrates
health considerations into non-health sectors; it recognizes that “corporate boardrooms, legislatures, and executive branches” make choices that profoundly affect health.11 Additional research is critical to determine whether HiAP leads to decisions that are more likely to consider health16 and, ultimately, improve it.Nonetheless, HiAP is a promising approach consistent with solving complex social problems through the “collective impact” of multiple sectors collaborating around a common agenda.19 These sectors include transportation, agriculture, housing, employment, planning, business, education, and energy, and in federal, state, and local government, they are often connected to agencies charged with regulating or facilitating their work."
The article goes onto suggest that legislation is a good way to implement HiAP. " But how do governments implement HiAP? Consistent with law’s contributions to improving the public’s health,law can be “an important tool for institutionalizing an infrastructure for HiAP and for requiring agencies to ensure that the policies they pursue serve . . . health.” Governments use law to integrate health into other sectors.They also use legal mechanisms to further cross-sector collaboration around health, which is a critical component of HiAP.
Since an effective HiAP strategy will require practical applications to inter-sectorial work, we suggest strongly that any introduction of an HiAP strategy will require the health sector to go to the venues or settings where the other sectors actually deliver their services and programs such as workplaces, municipalities, schools and other places. In other words, the health sector will need to return to a settings-based health promotion strategy if it expects ongoing cooperation from the other sectors. Otherwise the HiAP strategy runs the risk of being perceived as the health sector dumping its work onto the other sectors and they will resist, delay or simply not cooperate.    
The articles suggests that government levers can be used in several ways. Let's take a quick look at how many of these strategies are used to promote intersectorial cooperation through comprehensive, whole of government approaches to school health promotion.

1. Requiring collaboration: Law can create legally binding duties for departments to collaborate around health. This can be required at the national, state or local agency level.
   To our knowledge, there is no government that requires such cooperation by law for SH promotion. Many appoint officials and some even huave joint SH progrrams or committees, but this is not done in legislation. 
2. Authorizing collaboration. Even when law does not require cross-sector collaboration around health, it may permit it. This permission may be direct and explicit. Or, Law may also authorize collaboration around health implicitly, through broad grants of public health authority. -- Many governments authorize their health ministry staff and local health authorities to cooperate with school systems. But often the funding and staffing for this cooperation is not provided to the SH team. Usually funding for prevention and promotion work is delivered through other sections of the health ministry rather than the SH team or any other teams that have responsibility for working with the other sectors/settings. 
3. Establishing institutions for collaboration. Law can organize and implement collaboration by formalizing relationships through task forces, boards, commissions, or other institutions. -- To our knowledge, there is no government that has established an inter-ministry SH structure by law, although several exist by administrative decisions. These administrative structures often are changed when a new elected or appointed official decides to re-structure the huealth ministry to address new priorities, often focused on urgent health issues rather than ongoing relationships with other ministries. We have seen some structures on child or family health established by law but often they are not successful and often they are focused on urgent problems rather than long term solutions such as SH or on inter-ministry, inter-sectorial relationships. 
4. Prescribing a collaborative process. Governments can go beyond generally requiring or authorizing collaboration to prescribe specific collaborative processes. 
   Again, to our knowledge, there is no government that requires that a collaborative process within the health ministry, across ministries or among local agencies to promote health through schools. In many cases, there are committees, but their existence and use by the various ministries and agencies is always voluntary. Often such committees seldom meet. There are no requirements for ministries or agencies to cooperate in order to receive funding. There are few jointly appointed staff teams or coordinators. There are seldom any joint reporting requirements.
5. Assigning responsibility. The law can be used to assign responsibilities for cooperation and joint action. Often there are SH coordinators assigned within the health ministries or local health authorities. Sometimes these coordinators are assigned within the education system. However, often these coordinators are responsible for other duties. Often any funding that they have available to work with are focused on specific health issues or programs other than school health. 
6. Prioritizing a public health issue. Law can elevate a particular public health issue and focus the efforts of different agencies on that issue. 
   In our view, this suggestion  reflects a health sector bias, one that is most often focused on a disease or specific health problem. We recognize that this is how the health sector really works, but this tendency to ignore overall "health" to focus on the "absence of disease" will prevent any long-term cooperation with and within other sectors. If the health sector is unable to moderate this tendency and modulate its activities with other sectors to help them meet their respective goals and primary concerns, then all of the health checklists newly dressed up and prepared as part of a HiAP strategy will not be sustained. 
7. Coordinating government efforts. For a complex problem (or solution) such as homelessness (or healthy schools), requiring attention from several agencies, law can encourage agencies to work in concert and in consistent and complementary ways. -- The research on school health and other forms of health promotion and social development is now clearly recognizing the complexity involved in working within and across sectors. The authors note that " By requiring each participating agency to assign a representative responsible for homelessness (school health) with authority to bind the agency to the Council, use standard data, and contribute resources,the statute promotes consistent and complementary work. It also encourages working in concert by requiring the Council to survey available resources, provide and coordinate state services, improve information flow, establish a resource and information center, and develop monitoring guidelines." To our knowledge, there are few, if any SH councils in the world mandated by law in this manner. 
8. Providing for funding. Collaboration or executing collaborative recommendations may require funding. Law can create public finance infrastructure and provide and incentivize funding through appropriations, grants, or social impact bonds.
   In school health promotion, there are many, many bits and pieces of project funding, often offered to schools in short term competitions. But there are no funding incentives of the scale that would encourage federal departments, state ministries or even local health and education ministries to work together over the long term on school health promotion. 
9. Fostering informal relationships. Laws formalizing collaboration around any issue can improve relationships and create opportunities for future collaboration by requiring the participation of senior leaders within ministries (rather than program level staff), requiring a minimum number of meetings or reports. -- As noted above there are often such committees, but they are often have low level participation and few requirements about their joint work. 

This article on how HiAP strategies can be implemented through legislation is both useful and revealing. The many suggestions, illustrated by practical examples in the United states, are very applicable to school health promotion. The analysis also reveals a fundamental challengre to the successful implementation of HiAP in any jurisdiction. If it is used as a sledge hammer to require other sectors to work on then many urgent health problems of the day, rather than a way to re-establish long-term relationships and joint approaches that help those other sectors achieve their priorities (such as school health promotion) with other sectors, its shelf-life as a viable whole of government strategy. Read more>>