Challenging Health in All Policies, an action research study in Dutch municipalities

Abstract

The Dutch government encourages municipalities to develop ‘Health in All Policies’ (HiAP). The development of such a policy requires inter-sectoral collaboration, however municipalities show little initiative in this regard. Operating in an advisory role, the regional Public Health Service (PHS) has supported municipalities in South-Limburg in setting up inter-sectoral collaboration. A coaching program for municipal stakeholders was developed and implemented to improve HiAP, using obesity as an example.

To determine the effectiveness of this coaching program, civil servants, managers and municipal councilors were invited to fill in an Internet questionnaire prior to and at the completion of the program. By means of a log-book all activities were registered in coached municipalities and in-depth interviews were held with municipal managers. Outcomes were scored depending on the stage of HiAP proposals.

Six of the nine coached municipalities showed concrete outcomes in terms of HiAP proposals. The results show that more support and involvement at each system level stimulates the development of HiAP. The program contributed positively to the implementation of HiAP interventions targeting obesity. The pretest results for coached municipalities were better compared to non-coached municipalities. However, after 30 months of coaching this positive starting position faded away. We recommend that the municipal management become more involved in the development of HiAP and advise the PHS to increasingly demonstrate their expertise. Here lies a challenge for municipalities and their regional PHS.

Introduction

In the Netherlands, as in many countries worldwide, local governments are held responsible for local public health policy by national law and are obligated to work together with a Public Health Service (PHS, in Dutch GGD) [1]. Municipalities have a central role in providing Public Health Services to improve health and to reduce socioeconomic health inequalities [2]. Lower educated people in the Netherlands live 6–7 years less than those who are highly educated, and they live 14 years longer in poor health [3]. This fact in combination with the high prevalence rates of chronic diseases, obesity and mental health problems implies the need for solutions outside the health domain, which has been cited as ‘Health in All Policies’ (HiAP) [4], [5]. The complex policy challenges posed by obesity (40–50% of the Dutch adult population is obese [3], for instance, are a good example of the rationale underpinning the presumed need to work in policy networks to tackle this public health concern. Policy domains such as Spatial Planning & Environment, Social Affairs, Traffic & Transportation, Public Safety, Youth & Education, Recreation & Sports need to be involved [6]. So far, there is limited knowledge about how to organize these partnerships at the local level nor the outcome: obesity prevention [7].

The Dutch government encourages municipalities to develop HiAP. The development of such a policy requires inter-sectoral collaboration, however municipalities show little initiative with regard to inter-sectoral collaboration [8], [9]. There are very few mechanisms that stimulate local policymakers outside the health domain to consider health determinants and health impacts. Usually each policy domain works to its own logic and own performance indicators without regarding the impact certain measures may have on health of the population. The method of Health Impact Assessment (HIA) provides an opportunity to discuss the health impacts of measures taken by non-health domains but recent research has indicated that this tool is not very effective in the Netherlands. The current emphasis of HIA on a technocratic and rational decision making design obstructs rather than facilitates the integration of health in public policy [10], [11]. The evidence-based reasoning in HIA appeared to be not effective, so far. These negative results encouraged the emergence of a coaching program based on the principles of knowledge sharing and dialogue and creating the necessary white space conditions for further progress [12]. Municipal authorities have to define Public Health policy. In most policy plans since 2006 the importance of an integrated approach to, for instance, the obesity problem, is proposed [13]. Operating in an advisory role the regional PHS South Limburg together with the National Institute on Health Promotion and Disease Prevention (NIHPDP) developed a coaching program for nine municipals in the region to collaboratively find ways to improve HiAP, using obesity as an example.

The process from policy preparation to policy decisions is a hierarchical process, with municipal councilors having the final say, managers or heads of departments in between and the civil servants at the bottom. Therefore, the coaching program distinguished between stakeholders at the strategic or administrative, tactical or managerial, and operational or executive level. A conceptual framework was developed based on theoretically essential determinants of inter-sectoral collaboration, marked in italics, to stimulate inter-sectoral collaboration within and between policy domains [14] (see Fig. 1). The logic behind it is that the realization of HiAP requires agenda setting of a special health concern at the administrative level to give the issue political priority [15], [16]. Administrative commitment and leadership are both essential elements to propel an issue onto the political agenda of different policy domains [17]. When policy stakeholders at the administrative level consent to political priority setting, the policy preparation process can be initiated. The managers can facilitate or restrict civil servants in their activities at the executive level. They will have to facilitate the transition towards more collaboration between municipalities’ policy domains including their regional PHS. The transition poses challenges with respect to organizational culture, managerial support and policy capacity [18], [19]. Policy capacity relates to available human resources in terms of time, competence, and capability i.e. the ability to adapt to change, generate new knowledge, and continuously improve performance with colleagues in other policy domains [20]. Having realized the preconditions for collaboration at the tactical level, the different executive professionals can initiate co-operation at the operational level. Knowledge, attitudes, perceived social and outcome expectations, and self-efficacy seem to be important personal determinants of both judging one's own policy frame of reference and of entering another policy domain [19].

This constitutes a system level approach in which collaboration is viewed as a function of individuals and of the environments in which individuals operate. The various levels are viewed as embedded systems [21]. The conceptual framework illustrates the reciprocity between the stakeholders at each level within a municipality, i.e. municipal councilors, managers and civil servants. To create inter-sectoral collaboration the usual communication in a vertical, hierarchical direction needs to be supplemented with communication horizontally between the different policy domains at each system level (see Fig. 1).

This study seeks to structurally map and explore the effectiveness of a coaching program which was implemented by the regional PHS South Limburg and the NIHPDP. The aim of the study is to see if municipalities are able to make progress in inter-sectoral collaboration at the strategic, tactical and operational level and in the assessment of HiAP proposals. Findings from this study could help policy makers and PHS-professionals understand how to more effectively develop HiAP proposals.