HiAP: Ensuring the Health of all Populations
By Jerome Williams, UNA-NCA Research Assistant
Covid-19 has exposed and exacerbated existing inequalities in access to quality health services among communities. Race, ethnicity, location, and economic status are compounding and interrelated factors that shape the landscape of health outcomes across the country, from maternal mortality rate to health insurance coverage. In New York City, Black & Latino Americans are 2 times more likely to die from Covid-19 than white Americans. In Arizona, Native Americans comprised 16% of Covid-19 related deaths while only representing 4.6% of the state’s population. The underlying issues that contribute to these disparities stem in part from the conditions of the neighborhoods in which vulnerable populations reside.
The Vanderbilt University Medical Center determined that stresses caused by discrimination, lack of access to social services, dependence on public transportation, and even lack of proximity to parks increases susceptibility to Covid-19, among other health issues, due to immune system impairment. The medical center created a “health equity workstream” — consisting of data related to race, ethnicity, English language proficiency, and ZIP code- to effectively address these disparities and help Covid-19 patients.
Health outcomes are not solely dependent on biological factors such as genetics — they are shaped by social, cultural, and environmental determinants. Addressing the root of health disparity by comprehensively changing the landscape of resources in communities will better equip leaders and citizens to tackle health issues beyond Covid-19, from obesity to pollution-induced asthma. Policymakers across all sectors of government should be aware of how their decisions impact the health of all communities when implementing plans. The Health in All Policies framework (HiAP) was created toensure that policymakers are informed about equity, sustainability, and health consequences throughout decision making processes. The World Health Organization (WHO) defines HiAP as:
“an approach to policy-making that places ‘health’ as a key decision-making factor in all areas of policy, by systematically taking into account the health and health-system implications of policy decisions, by seeking synergies between policy portfolios, and by avoiding harmful health impacts, in order to improve population health and health equity.”
The phrase “Health in All Policies’’ was first used in 2006 by the European Union with the Finnish Ministry of Social Affairs and Health publishing a strategy guide detailing the principles and prospects of addressing complex health issues with intersectoral solutions. The guide led to other governments adopting the framework, with the Government of South Australia (SA) adopting a model of this new health paradigm for their state in 2007. SA’s government created an initiative in 2009 under the HiAP model to improve road safety for Aboriginal citizens. Regional departments partnered to respond to the issue of Aborginal people being 3 to 5 times more likely to die in a traffic-related accident. A major contributing factor for this health disparity was that a high percentage of these citizens were unlicensed drivers. The initiative expanded licensing programs across urban and rural areas, increasing life expectancy rates and combating unemployment in the Aboriginal community. South Australia’s practices helped facilitate further development of the HiAP framework in subsequent years as a case study for other countries to follow.
HiAP has been influential in policy making in various regions around the US. For example, government staff and medical experts in Summit County, Ohio analyzed zoning ordinances in the county that inhibited bike lanes and access to grocery stores in low-income, underprivileged neighborhoods. This research revealed a relationship between obesity and race, with disproportionately high rates among African-Americans. In 2013 the city partnered with Change Labs Solutions — an organization that assists communities addressing health equity issues — to develop a community-led HiAP initiative to efficiently and effectively remedy health disparities. The Summit Coalition For Community Health Improvement advocated for Akron’s “Complete, Livable and Green Streets” ordinance, which was passed in 2017 to address the connection between health and infrastructure.
Cities have also worked to change the social culture to improve health. California’s HiAP task force released the Action Plan to Promote Violence-Free & Resilient Communities in 2016 in order to address disproportionate violence that communities experience along the lines of race, sex, and socioeconomic status. The action plan has three primary goals :
1) Increase awareness of trauma experienced in families;
2) Promote policies and practices that prevent violence through the environment for vulnerable communities;
3) Building the state’s capacity and state employees’ ability to identify underlying causes of structural violence (such as racism and sexism).
Richmond, CA addresses violence in its HiAP strategy by identifying “toxic stressors” — racial profiling, lack of recreational resources, and economic insecurity — which contribute to violence. Richmond’s police department coordinated with the Department of Justice’s Violence Reduction Network to train officers in de-escalation strategies and implicit bias training to effectively address racial profiling.
While there are various case studies of HiAP in action, critical components are missing from ensuring that HiAP plans are effectively practiced. Of the 41 jurisdictions that have adopted the framework globally, only 13 are considered to be “established” — defined as framework being mandatory within a jurisdiction and making positive progress with implementation of policies — according to the Global Network for Health in All Policies. In order for HiAP to work effectively in the “established” capacity, the Wellesley Institute identified six necessary factors
- Participation from departments and agencies across government needs to be required through legislative, regulatory or policy directives.
- Forums to share experience and collaboratively analyze the health implications of policy directions and programs, and technical support from central agencies
- Facilitation through proven tools such as Health Impact Assessment or Health Equity Impact Assessment
- Requirements need to be matched with explicit deliverables and targets for departments and agencies
- Transparent reporting on progress for targets
- Incentives so that funding allocations for relevant departments and organizations are tied to delivering on wider social determinants and health equity expectations.
What most HiAP plans have lacked is transparent reporting and incentives to involve departments and organizations. For example, the website for the Pan American Health Organization’s regional plan — adopted in September 2014 — fails to depict data from initiatives in the Americas despite multiple strategies existing in jurisdictions of the region. The Association of States and Territorial Health Officials (ASTHO) reported that states like Massachusetts, Conneticuticut, and California have difficulty reporting data for initiatives as well as securing funding. ASTHO has also identified that these issues typically occur depending on whether a municipality uses an informal or formal system of implementation. In California’s formal approach, enforced by laws, cities within the state do well at implementing strategy but have trouble measuring health impacts. In Connecticut’s informal approach, operating through voluntary coalitions across multiple sectors, cities lack funding for their programs.
This common issue of varying gaps in results can be seen globally, as countries without national commitments to compliment municipal progress struggle to effectively address and measure health issues. A nationalized mandated structure for HiAP in Australia has been advocated for in the wake of the Covid-19 pandemic in order to sufficiently deal with the complexities of the health landscape. A nationalized model would establish collaboration across all sectors of government and help develop an appropriate measure for reporting data. Joy Mauti, a fellow at the Global Health Centre-Graduate Institute Geneva, states that,in the context of African nations, “You have to make every sector understand that health is important, so they can even budget for HiAP within their own activities”.
While Mauti spoke in the context of Africa, the principle still applies universally. All sectors of government must cooperate in a horizontal collaboration to report experiences and progress rather than a vertically mandated or top-down policy. Sudan is a successful case study of implementing a nationalized policy utilizing the HiAP framework. Since 2015, the country has developed a strategy which includes elements such as a multisectoral approach for planning policies, transparency of progress, and legislation to support health programs. More cities and countries are adopting HiAP strategies around the world to prepare for and address shocks like the Covid-19 pandemic. Central and local governments will be integral in the success of these new strategies.
Covid-19 reinforced the link between environment and health and that comprehensive, preventive approaches towards public health are more important than ever. HiAP is a tool that governing bodies can use to ensure that health equity is achieved in every sector of life for all citizens but only if implementation is mandated, done with a multi-sectoral approach with non-health and health department stakeholders, and progress is transparently measured and reported.