We conducted interviews and surveys of government staff. The research participants were categorised by the sector in which their department/agency was located (health, industry, governance, etc.). Departmental names and structures changed frequently during the research period.
We judged SA HiAP to have made a modest contribution to actions likely to improve health in the state, relative to its small budget (0.00948% of the Health Department’s 2015-16 budget). The reasons for its success were political will and a supportive policy network.
Social Determinants of Health
The social determinants of health (SDH) are the conditions in which people live, such as education, income, job opportunities and housing. These factors influence their health and well being in a range of ways such as food insecurity, lack of economic mobility, interpersonal violence, poor mental and physical health, inadequate social support and poverty.
In order to improve population health and reduce inequities, government action across sectors is necessary to tackle the SDH. A common approach to this is the Health in All Policies (HiAP) initiative which involves incorporating consideration of health and wellbeing into government policymaking. HiAP has been implemented in South Australia for over 10 years. Key drivers for the longevity of HiAP include a clear political mandate, a move from a short term project focus to institutionalisation through new public health legislation, finding a fit between the HiAP ideas and the dominant economic paradigm of government, and supporting a network of policy entrepreneurs and champions.
To evaluate the impact of HiAP, a mixed methods study was conducted including 144 semi-structured key informant interviews; two electronic surveys of government public servants in 2013 and 2015; analysis of state government policy documents; and construction of a program logic model to shape assessment of the feasibility of attribution of HiAP activities to population health outcomes. The results showed that a strong and committed leadership from the SA Health Department along with flexible partnership practices and processes have been important enablers of the success of HiAP.
Despite the high level of interest in the social determinants of health by the government and its agencies, HiAP has been challenged to make the case that it can contribute to achieving health equity goals. It has achieved its core goals of facilitating joined up government for co-benefits, but the more distal intent to address the inequities that underpin poverty and disadvantage has not gained as much traction. This reflects the fact that HiAP is being implemented at a government level which does not control the basic structures of society that determine inequalities and so is limited to the implementation of initiatives which change daily living conditions and do not redistribute resources.
In our analysis of the early implementation of HiAP in South Australia we consider how other sectors became involved and what has contributed to the success or otherwise of a health in all policies approach. Our analysis draws on a subset of 112 interviews conducted as part of the wider HiAP evaluation; 49 interviews with staff from departments/agencies other than the Department of Health, 54 with Health Department staff and five with academics who were involved with HiAP.
A number of factors appear to have been influential in the development of a supportive policy network. Firstly, there was general acceptance that health is influenced by social determinants outside the health sector and that the health in all policies approach provides a valuable mechanism to influence work across government on these determinants of health. Secondly, the support and enthusiasm of a small group of champions and policy entrepreneurs has played a critical role in supporting and disseminating understanding of healthy public policy and the social determinants of health. These individuals were able to build relationships, provide leadership and create the momentum required for a health in all policies initiative to gain traction within the bureaucracy.
Thirdly, the transition from a short term project focus to institutionalisation through new public health legislation helped give the HiAP approach greater longevity and legitimacy. The introduction of the health in all policies policy mandate also provided a clear political mandate for Health Department and allied agency staff to continue working with their colleagues across government on policy initiatives that had a direct impact on the health and wellbeing of South Australians.
Lastly, the alignment of HiAP ideas with the dominant economic paradigm of government provided further support for the ongoing existence of the HiAP policy mandate. The focus on a ‘State of Wellbeing’ and the linking of health to the strategic priorities of Economic Development and Growing Advanced Manufacturing meant that health was framed as an economic concern.
Nevertheless, there was a drift in the emphasis on equity as a key goal of the HiAP approach and a move to view it predominantly as a process for facilitating joined up policy across the SA Government. This occurred at a time when the economy in South Australia was less buoyant and a new health minister with a different perspective on the role of prevention took office.
The South Australian government provides a range of health services. These include public hospital care, disability support and a family planning service. It also provides a large number of community health activities such as child and maternal health, aged care and chronic disease prevention. Health and safety is a major concern for the government. It provides a large number of fire and ambulance services and has one of the largest networks of community health workers in Australia.
The SA government aims to improve population health by setting health goals and targets in its Strategic Plan. It supports these goals by providing funding and by ensuring that other sectors take health into account in their policy work. It also promotes the use of a systems map to help identify areas of interest to the state’s residents and communities.
This map shows the relationships between key government policies, programs and plans, and outlines how they interact with each other. It is a tool for understanding how the different parts of the system connect with each other, and what effect these interactions may have on health outcomes.
The SA HiAP initiative was a multi-year policy network that brought together a wide variety of people to facilitate joint policy work across departments and agencies for co-benefits. Its key strengths were: a dedicated budget, the support of senior leaders with clear mandates, a shift from a project focus to institutionalisation through new public health legislation, a network of policy entrepreneurs and champions and a culture change in which the idea that healthy public policy was an important consideration in all sectors had become common knowledge.
Although SA HiAP was successful in generating many policy actions that improved daily living conditions, it failed to address the underlying drivers of health inequities and was constrained by its budget and institutional context. Its main impact was in encouraging other government sectors to be more aware of the links between their work and health. Its future impact will depend on building a strong constituency for more structural changes and increasing the political will to act on the social determinants of health.
The research undertaken in this project has highlighted that, while Health in All Policies (HiAP) was a catalyst for improved policy coordination across government departments in South Australia, the initiative was limited in its impact on health inequalities. This is because it failed to address the broader drivers of health inequalities, particularly the structural factors that govern the distribution of power and resources.
The HiAP model has the potential to improve policy coherence by facilitating agencies to routinely consider and account for the health impacts of their policies. However, it requires a strong commitment to a policy approach to health that is embedded in a political culture that supports it. In HiAP, while equity was evident in the language of the 10 Principles, it progressively slipped from SA Government documents that identified and articulated government agenda and priorities. As a result, HiAP became seen by government agencies as a useful process for improving intersectoral policy development (which could still include some focus on population health and wellbeing), rather than as an initiative to improve equity through intersectoral policy development.
This is due to a number of reasons. While there was a broad acceptance of the role of the social determinants in shaping health, there was less agreement about the nature of the problem or how to tackle it. In addition, there was a lack of a common vocabulary or agreed approaches to measuring health impact. These factors combined to limit the extent to which agencies were willing to work with other departments under the HiAP umbrella.
Despite this, the HiAP initiative was successful in avoiding a lifestyle drift in strategy and encouraging other departments to focus on population-wide issues and interventions. It also helped to build awareness about the broader impacts of their sectors’ policies on population health. This was facilitated by the fact that a dedicated HiAP unit was established in Health.
Nevertheless, the five years of research in this project has indicated that the HiAP initiative was only partially effective at changing government departmental attitudes and behaviours and can only be judged to have made a modest contribution to actions likely to have improved population health. It was constrained in its ability to affect the underlying economic and power distribution factors that shape health inequalities because it was implemented at a level of government which did not control many aspects of the distribution of resources. It was also designed to rely on building consensus and seeking ‘win-win’ strategies.