HiAP – A Tool for promoting equity by tackling root courses of health disparities
Writer: Danielle Thonton, St. Catherine University, Minnesota, USA
Editor: Khanitta Saeiew, NHCO Thailand
The concept of Health in All Policies (HiAP) emerges as a crucial strategy for addressing health disparities and promoting health equity through collaborative efforts across diverse sectors beyond healthcare. It recognizes that health outcomes are profoundly influenced by social determinants such as education, income, housing, and the environment, alongside traditional healthcare services. The World Health Organization (WHO) underscores the necessity of integrating health considerations into policymaking across all sectors to ensure that health is not relegated to a secondary role but is a fundamental consideration throughout decision-making processes.
During the 2021 World Health Assembly (WHA), the Member States of the WHO requested the Director-General to “foster and facilitate knowledge exchange among Member States and relevant stakeholders on best practices for intersectoral action on the social, economic and environmental determinants of health in order to achieve health equity and gender equality for all”. In response to this request, WHO established the Global Network on Knowledge Development and Exchange for Health Equity. And in 2023, WHO just launched the guidance on Working together for equity and healthier populations Sustainable multisectoral collaboration based on Health in All Policies approaches (HiAP). The guidance aims to provide a new model of HiAP called 4 pillars for HiAP namely 1) Governance and Accountability 2) Leadership at all levels 3) Ways of working for HiAP action 4) Resource, Financing and Capabilities.
In collaboration between the Global Network for Health in All Policies (GNHiAP) and the WHO Global Network on Knowledge Development and Exchange for Health Equity organized the webinar on Health in All Policies: Advancing Multisectoral Collaboration for Health Equity on June 19,2024 to explore how HiAP can serve as a tool for promoting equity by addressing the root causes of health disparities and inequities that are influenced by factors beyond healthcare with case studies from various countries.
In the webinar, Dr. Etienne Krug, Director of the Department for Social Determinants of Health at the WHO in Geneva, Switzerland. highlighted the need of global collaboration and knowledge exchange to effectively address social determinants of health and improve health equity on a global scale. He also emphasized that it needs to ensure health considerations are integral to policy-making across all sectors, not just an afterthought. These networks can be used to initiate a global dialogue among government focal points and ensure people are working together on development and dissemination information.
Dr. Nicole Valentine, Technical Officer, WHO stated that since the Helsinki Statement in 2013 provided the definition of HiAP, countries around the world have been working on understanding and practicing HiAP. But now, the next chapter focuses more on seeking synergies with other sectors. Therefore, WHO introduced the four pillars of HiAP to provide practical guidance. These include creating an authorizing environment and mandate to legitimize multisectoral work, establishing layered cross-government committees, forming a cross-government working group, and having leaders who can connect with other agencies to foster a culture of collaboration needed for HiAP. Throughout her presentation, Dr. Valentine outlined actionable steps to bridge working silos and invited three panelists from Thailand, Iceland, and Kenya to present their case studies.
Dr. Tipicha Posayanonda, Assistant Secretary-General at the National Health Commission, National Health Commission Office (NHCO) Thailand, stated that Thailand case study highlighted health inequity among school children, some of them lack proper meals from home and lack of money to buy lunch at school if it isn’t provided free of charge. Schools are expected to help to narrow the equity gap.
She also highlighted that NHCO’s strategy on integrating social determinants of health (SDH) and HiAP into public policy through participatory policy processes under the National Health Act 2007 and outlined key mechanisms such as the National Health Commission and the National Health Assembly Follow-up Committee who facilitate multisectoral collaboration.
A key focus of Thailand’s initiative was to address health equity through the school catering system policy, which was initiated following a resolution at the National Health Assembly. This resolution and related multisectoral works led to pilot provinces to use local ingredients, revise the fund management committee regulations, and increase funding for school meals. Posayanonda spoke on the importance of governance bodies like the National Food Committee and the National Health Assembly Follow-up Committee in policy development and monitoring. She also highlighted the leadership of local administrative authorities and community engagement in implementing these policies at provincial and community levels. She mentioned that government resources for HiAP works were allocated to several health agencies for meetings and studies related to the Thai School Catering system.
Gladys Mugambi, the head of the Health Promotion Department in Kenya, discussed Kenya’s efforts to address the triple burden of malnutrition through a multisectoral approach. The country’s strategy began with the development of the Food Security and Nutrition Policy in 2012, involving collaboration among the Ministry of Health, Ministry of Agriculture, and Ministry of Planning. This policy framework enabled Kenya to join the Scaling Up Nutrition movement and establish a comprehensive multisectoral nutrition plan. By mobilizing resources from diverse sectors including education, social protection, agriculture, and international partners, Kenya significantly increased funding for nutrition initiatives. This coordinated effort also improved governance through regular national technical forums and quarterly meetings, enhancing policy implementation and monitoring across sectors.
Kenya has achieved notable reductions in malnutrition indicators from 2008 to 2022, including a decrease in stunting from 35.3% to 18% and underweight from 16% to 10%. These improvements underscore the effectiveness of multisectoral collaboration in addressing complex health challenges. Mugambi emphasized the importance of advocacy, clear multisectoral plans, and resource mobilization as key factors in achieving these positive health outcomes. Her presentation highlighted the critical role of governance structures in aligning various sectoral priorities with health objectives, ultimately improving health equity and well-being for Kenyan communities.
Gigja Gunnarsdottir, National Network Coordinator, Directorate of Health, Public Health Institute in Iceland shared her insights into promoting well-being for all within health-promoting communities. Gunnarsdottir highlighted Iceland’s demographic and administrative structure, she noted the country’s focus on public health indicators and targeted interventions across municipalities and health districts. She shared challenges such as limited sample sizes and data gaps and the increased need for initiatives to improve inclusivity in health assessments.
Gunnarsdottir showcased Iceland’s adaptation of the Health Determinants Rainbow Model, tailored to local contexts and Sustainable Development Goals (SDGs). This model delineates individual factors, lifestyle choices, and socio-economic conditions impacting health outcomes, highlighting the importance of sectors beyond healthcare in promoting equity. She also outlined governance structures supporting intersectoral collaboration, including steering groups and checklists linked to SDGs, aimed at monitoring progress and fostering dialogue across sectors. She shared challenges in making these efforts sustainable such as the challenge of personnel large workloads and the need for extensive groundwork before implementing collaborative approaches. She also emphasized the importance of having language that focuses on well-being narratives to facilitate dialogue across sectors.
Towards the end of the webinar, both Gunnarsdottir and Posayanonda shared some key lessons for the audience to consider including the importance of program preparation and adaptability. They highlighted the fact that building trust and understanding among sectors requires not only formal mechanisms but also informal opportunities for dialogue and adjustment. Posayanonda from Thailand, emphasized the complexity of measuring impact and monitoring health in all policy initiatives. Thailand faces difficulties in assessing long-term health gains amidst changing political landscapes and bureaucratic challenges; a robust monitoring and evaluation framework is needed from the beginning. Establishing clear indicators aligned with health equity goals can help track progress effectively and adjust strategies accordingly.
In conclusion, the insights shared by the panelists emphasized the significance of readiness, flexibility, rigorous evaluation, and fostering alliances to overcome obstacles inherent in deploying health in all policy strategies. These learnings offer valuable guidance for nations aiming to emulate such approaches, enhancing public health results through cooperative governance.