Background
Methods
Documentation of key events and documents
Semi-structured interviews
Analysis of interviews
Surveys
Data analysis
Results
HiAP action initiated in other sectors
I just think all of that knowledge and learning and opportunity we had that came out of HiAP is one amazing thing… and that continues on, like those people are spotted around, those projects are around, those outcomes are around (Executive/Senior management, Governance sector, 2016).Table 1Implementation of health in all policies in South Australia (2009 to 2016) showing sectors involved
Description of initiative Key sectors involved Intermediate or health outcome claimed Parental Engagement with Literacy Health Lens Analysis (HLA) Education Change to Education dept. literacy and numeracy policy regarding parental engagement Aboriginal Road Safety- Drivers Licensing HLA Emergency services; Transport; Justice; Correctional services; Education Minor increase in Aboriginal people with driver’s licences in remote communities, which is likely to reduce road accidents and incarceration rates Promoting International Students’ Health and Wellbeing HLA Education; Multicultural Resources for international students on health services access and maintaining well-being produced Healthy Sustainable Regional Communities in the Upper Spencer Gulf HLA Primary industries; Trade & economic development Awareness of importance of considering health and equity issues in regional planning increased in trade and economic portfolios and data atlas to support this Healthy Weight: A Desktop Analysis and Implementation Plan Health; Planning & infrastructure; Community services & welfare; Primary industries; Environment & natural resources; Education; Correctional Services; Justice Large range of departments made aware of the impact they have on population average weight and the potential actions they can take to achieve the healthy weight target. Progress on strategies within departments reported to Parliament annually Health Promoting Transit-oriented Developments (TODs) HLA Planning & infrastructure; Transport; Urban planning & development Contribution to development of suburbs that have lower ecological footprint and which encourage walking, cycling and use of public transport. Produced tool to assess health impacts of future TODs Local Government HiAP Approach: Castle Plaza Transit-orientated Development HLA Local government Greater awareness of health issues that may be associated with the TOD Active Transport – Economic Assessment for Cycling and Walking and Cycling Strategy Planning & infrastructure Strengthening the case for better provision for cycling and walking by providing health and well-being rationale Regional Migrant Settlement Trade & economic development; Multicultural Minimal impact but provided some rationale for considering health and wellbeing in migrant settlement Alternative Water Supplies – Water Security Environment & natural resources Raised awareness of potential positive and negative health impacts of increasing the re-use of stormwater, greywater and rainwater during policy development process Digital Technology: Increased Broadband Use Education More awareness of the importance of broadband access in terms of gaining access to social determinants including employment, education and housing and the health equity implications of some groups not gaining access Provision of advice, evidence and capacity building around how the cross-sectoral 7 Cabinet Priorities can contribute to health and wellbeing: Each of the 7 Strategic Cabinet Priorities were led by Ministerial Taskforces supported by Senior Officers Groups. Initially these were led by Premier and Dept. of the Premier & Cabinet (DPC), in partnership with Minister and the government department with primary responsibility for policy issue. Over time the relevant Minister and department took on primary responsibility for each of the priorities. Bringing an awareness of the health impact of the work of each of these taskforces and encouraging them to make health a key consideration - Every Chance for Every Child: Capacity building across Government Premier and Minister for Education supported by DPC and Education sector - Safe Communities, Healthy Neighbourhoods Premier, Commissioner of Police and Minister for Health supported by DPC, Justice, Health - An affordable place for everyone to live Premier, Treasurer supported by DPC and Finance - Realising benefits of mining boom for all Premier, Minister for Industry & Trade supported by DPC and Trade & economic development - Premium food and wine from our clean environment Premier, Minister for Primary Industries supported by DPC and Primary industries - Growing Advanced Manufacturing Premier, Minister for Industry & Trade, DPC, Trade & economic development - Creating a Vibrant City Premier, Minister for Planning supported by DPC and Planning & infrastructure Premier’s Healthy Kids Menus Taskforce Health; DPC; key stakeholders including Australian Hotels Association, Restaurant & Catering Association and Clubs SA, Heart Foundation, CSIRO and Parent representatives- chaired by the Parliamentary Secretary for Health Recommendations for entertainment venues about how they can support healthy eating for families 90 Day Change Project – One Government: Working together for integrated policy that meets citizens’ needs Health, DPC, Office for the Public Sector, Environment & natural resources Lessons from the HiAP experience of cross sectoral working directly informed this initiative and underpinned the strategies developed as part of it Applying HiAP Principles to work with Public Health Partner Authorities (PHPA) across SA Involves a range of Government and non-Government partners, including:- Environment & natural resources. Policy focus is on healthy parks, healthy people- Planning & infrastructure. Policy focus is on planning reform, urban renewal and healthy built environment- SA Council of Social Services. Policy focus is on the role of non-government sector in public health planning system- University of South Australia. Policy focus is on research policy translation, social isolation, older people and the built environment- Community services & welfare. Policy focus is on whole of government Wellbeing Framework concept and measurement; increasing access to healthy nutritious food for vulnerable people at risk of hunger. Relatively new initiative (since 2015). The legislative basis of the PHPA promise to help health become more prominent in the activities of those agencies that sign up to be a PHPA
…the approach appears to me to have been ‘Well, here’s an issue. We think this needs to be tackled. We think it needs to be done like this.’ Whereas we, having that core sort of business responsibility, have already identified that quite solidly and have, you know, work in place (Education sector, 2013).
Dominant policy ideas in South Australia
Congested policy environment
In the 30 Year Plan [for Greater Adelaide] and the South Australian Strategic Plan, HiAP provided the opportunity to ask for each of the general policy propositions ‘what’s the overall health impact of this?’ which would not necessarily be asked otherwise. Whereas traditionally the questions have been economic impact, then environmental impact and sometimes social impact, but health impact has not been a traditional question in policy development. (Political staff, governance sector, 2013).
So what Health in All Policies has had to do is had to adapt to something in South Australia which has been quite difficult because we’ve still got the South Australian Strategic Plan but layered on top we’ve got the seven strategic priorities that they had to adapt and fit into. Then since the election we’ve got also another ten economic priorities and extra things happening… it’s sort of the principle of being at the centre of other people’s problems, like how do you help solve their problem with them and how can HiAP help, is hard when the landscape is changing so quickly. (Executive/Senior management, governance sector, 2014).
Commitment to joined-up government
…what I had seen before was always this incredible frustration of things being done in silos and being treated as symptoms… This was to get them from thinking narrow ‘this is my empire’ to thinking about ‘this is – we’re all in it together’. (Former Premier, June 2013).
Health in All Policies provides a potential template for engaging in other policy development processes, where the aim is to deliver an outcome for the state from a whole of government perspective, rather than the perspective of a single department. (Senior Executive, finance sector, 2013 survey).
When we do our planning work we have to look at transport issues, environmental issues, social equity issues and a whole range of other things and we try and merge those all together and balance them in one way or another. Until relatively recently the health elements, which oddly enough was one of the great reasons why planning was born, but the health elements had slipped off the agenda and what the Health in All initiative did was actually re-establish its place within a land use planning framework that could then enable us to craft and re-craft policy in different areas of our work, so in that sense for us it’s been a wildly successful initiative. (Senior Executive, planning and infrastructure sector, 2013).
Institutional context
HiAP in an institutional environment dominated by economic considerations
...then creates - anything that takes away straight commercial outcomes or economic outcomes means that the long term benefits of things like health, or even to the extent of, you know, what is sensitive urban design, etcetera, starts to not become high on the priority for what people are trying to achieve. (Urban planning and development sector, 2015).
I think there is significant pressure on our department to find millions of dollars of savings and effectively the response [to implementation of HiAP recommendations was] ‘We’re not doing it’ whereas before, you know, I think there was a real cooperative sort of approach. (Education sector, 2013).…so far so good, but in general when you get significant budget cuts it does tend to, as I said, pull your work right back to really what’s the core interest. (Environment and natural resources sector, 2014).
[this] is a huge risk to the HiAP process because nothing starts a stampede more than the first animal running and then everybody else runs away so there’s a risk around that… and the other reality is that we might find less willing partners at the moment because we aren’t able to offer as much as a health system in terms of our own resource. (Health sector, 2013).
We currently have a health system that has had health promotion and preventive health programs ripped out of it. (Community welfare, 2013 survey).
so in a sense what we were trying to do in a range of other areas, like with homelessness being joined-up responses, or joined-up responses in dealing with kids who are dropping out of school... here’s an area where in fact investment in health is actually about a better economy as well as a better society, more productivity. (Former Premier, 2013).
Formal mandates for HiAP
Currently based on personal relationships between officers, not part of the ‘system’. (Environment and natural resources sector, 2013 survey).
I think it was really too much to ask for them to have actually left a systemic change in the system. I think that the systemic change there is a broader challenge for public sector reform and looking at the Office of Public Sector Management… but I’m not witnessing - I wouldn’t say that I’m witnessing high levels of collaboration, at a systemic level anyway… so I think the collaboration stuff is a fairly isolated - it’s on an isolated basis rather than a generalised one would be my view at this stage. (Senior executive, trade and economic development sector, 2015).
Well [the impact of the Public Health Act] is still probably emerging but I think that whereas in the past Health in All Policies was a primary driver of the way in which Health was embedded across other departments’ policy agendas, I think now the Public Health Act is pretty much the main driver and I think Health in All Policies is having to kind of come in behind that and ensure that what it does is consistent with the intent of the legislation. I think it’s more about Health in All Policies adjusting to support the implementation of the legislation rather than Health in All Policies being a separate process in itself. (Governance sector, 2014).
Resources and management support
if Health in All Policies didn’t exist as an agency with the resources that are behind it, I think that there would be a risk that it would fall over. (Governance sector, 2013).I think one of the very real strengths is the HiAP team’s expertise… in getting high level access into other departments and having a strong imprimatur. (Health sector, 2013).
…they’re always there championing Health in All Policies. They’re quite – they’re out and about so they are, to me they are highly visible in what they do and how they do that, not only in Health but across government. (Health sector, 2013).…where Health in All Policies worked really well over the last, say, three to four years was that there was a dedicated unit and they drove it a lot. They got the people around, government around the table and supported implementation; they did project management to support the Health in All Policies programs. (Governance sector, 2014).
the HIAP Unit has the skills and the effort and dedicated resources… but it’s probably an unsustainable model. It needs to bubble out, out of the Unit and be the way that Health does business - or indeed how anybody in government does business… so it’s vulnerable but also it’ll only ever have limited impacts, so there’s four in a team or how many there is in the team, and they’ve got so much budget. It will – unless it leaves a legacy where people operate differently then – it will only ever be what it is and only have a certain amount of impact, which is probably different from being sustainable, but it’s only ever going to be limited. (Primary industries sector, 2013).
Strategic | |
• Establishing a broad shared strategic vision with other sectors and then determining how to achieve that in practice | |
• Managing up in health sector and across to Department of the Premier and Cabinet to ensure support for HiAP work, and building other external alliances | |
• Taking a helicopter overview of the entire initiative | |
• Monitoring the ways in which the public sector environment is changing and adapting to survive | |
• Watching for windows of opportunity to progress HiAP work and navigate recommendations through decision making hierarchies at times when success is most likely | |
Knowledge | |
• Working to understand the core agenda of other sectors | |
• Detailed understanding of SDH and how the core business of other sectors may influence population health | |
• Ability to interpret evidence and translate it in a way that is relevant to the core business of other sectors (e.g. evidence on link between literacy and health or evidence on links between urban planning, walkability and the creation of health promoting spaces) | |
Relational | |
• Being proactive and making cold calls to public servants in other sectors | |
• Building and fostering a broad and supportive network in public service for HiAP | |
• Relationship building which includes confidence with networking and making informal contact with actors from other sectors (eg coffee and discussions) | |
• Shepherding the on-going HiAP work from behind the flock by nurturing collaborations | |
• Confidence working at the boundary and linking organisations across different sectors | |
• Confidence to put the business of other sectors first, and to work with them to identify co-benefits to advance the other sector’s priorities while also addressing Health’s priorities |
Actors
Alignment of strategic objectives and the commonality of social factors that influence both education and health outcomes (2013 survey).
No more or less complex than any other. Simple idea, just a way of doing good policy… So the topics are complex but the broad aim of HiAP in terms of bringing people together to consider the health outcomes of policy is not that complex. (Governance sector, 2013).
Networks and champions
DPC’s a lead agency [for] Health in All Policies, so from pretty early days I’ve been one of the people driving the work within the South Australian government. There’s been lots of governance changes now and my job’s different now but I’ve continued that sort of role of being one of the central drivers and a central contact for Health in All Policies and other intersectoral sort of challenges basically. (Governance sector, 2013).
…I mean the fact that we have had other Chief Executives writing to our Chief Executive to talk about the importance and value of the work, I think those sorts of elements have been critical. (Health sector, 2014).
...but I think because I’ve had the interest in Health in All Policies and worked around it in other places it’s been like a sort of a natural progression for me to jump in and do some leadership. (Executive/senior management, environment and natural resources sector, 2016).
I think that the current members in the Strategic Partnerships Team, because they are the previous members of the Health in All Policies Unit, are trying their damnedest to, under the radar, maintain those relationships as best as possible because the cycle will happen again and I think the most important thing to protect are those relationships that were forged in the last four years, four to five years, because if they are affected then we’ll never ever get off the ground again, ever. (Health sector, 2014).
Discussion
- Supportive bureaucratic HiAP policy network | |
- Political mandate | |
- Move from project focus to institutionalisation and systematisation | |
- Finding a fit between HiAP ideas and the dominant economic paradigm |