Healthy Public Policies Begin with Health in All Policies
Marking National Health Week, Samanthi Bandara explores the concept of Health in All Policies (HiAP) in the Sri Lankan context and stresses the need to do more.
“Health” of the population in a country is not solely dependent on health sector activities alone. It is also determined by a variety of factors outside of healthcare services. These are referred to as the Social Determinants of Health (SDH). It is accepted that social factors such as, education, environment, working conditions, eating habits, leisure activities, influence people’s health. For instance, obesity, which in Sri Lanka is currently at 25% for women, and 17% for men, is a major risk factor for non-communicable diseases such as cardiovascular disease, diabetes, and cancers. It is linked to unhealthy diets, physical inactivity, harmful use of alcohol, and tobacco consumption. Therefore, many countries have made concerted efforts to integrate health considerations into other public policies which have an impact on health.
What is HiAP?
The rising importance of addressing social determinants began since the adoption of the Alma-Ata Declaration in 1978, in which “Health for All” was a key goal. Subsequently, the importance of Intersectoral Action for Health (IAH), which is the development of symbiosis between health and other sectors, was recognized as a vital mechanism when addressing the SDH.
Most recently, the concept of Health in All Policies (HiAP), was initially introduced by Finland in 2006. Subsequently, HiAP was recommended as a complimentary policy-related strategy to integrate health into other sectors in the ‘Adelaide Thinker in Residence’ in 2007.
The two concepts, which emerged in different eras, have significant differences. The concept behind IAH was that the health sector be directly involved at the policy implementation level in other sectors. The attempt was to get other sectors to also support the mitigation of health impacts. In contrast, HiAP requires that the health sector partnership with other sectors begin at the policy formulation level, and continue towards implementation as well as evaluation
The Sri Lankan context
Sri Lanka began intersectoral actions on health during the pre-independence era. Yet, the objectives of these initiatives were not strictly compatible with the concept of HiAP. However, it is important to look back upon these early inroads because they have laid the foundation for the implementation of HiAP. Some of these early interventions included the setting up of the National Health Development Council (NHDC) in 1979. The NHDC had the major responsibility of coordinating and reviewing the policy implementation in the health and health related sectors, ultimately reporting their strengths and weaknesses to the government, . In 1980, the country made the commitment to provide Health for All (HFA) by the year 2000, when the Prime Minster and the Minister of Health, together with the World Health Organization (WHO), signed the Charter for Health Development. Accordingly, the National Health Development Network was established to address IAH. Afterwards, the “National Health Council” (NHC), chaired by the Prime Minister, was established towards the end of 1980 as the governance tool at the Cabinet level to implement and coordinate IAH. Consequently, the NHC came to be seen as an apex body, ensuring political commitment on IAH. However, when looking at the key functions of the NHC carefully, it can be observed that the NHC functioned in some respects as a HiAP concept, in that it dealt with two out of three HiAP requirements – 1) policy formulation and 2) implementation. As per the available records, the NHC appeared to not be operational as of 2003. Following that, a variety of fragmented committees and task forces were established in the health sector to look after the concerns of SDH with support from other sectors, for example, the National Nutrition Committee; and the Presidential Task Force on Dengue. These committees remain fragmented. They do not represent a wide enough group of stakeholders to truly count as a national mechanism,capable of making a substantial impact on national health outcomes.
The International Example
Several countries argue that Health Impact Assessment (HIA) is the most appropriate governance tool in order to implement the HiAP, which can be used as an intersectoral strategy. This helps decision makers to gain better knowledge about public health. Further, as the study on the “effectiveness of HIA,” which looked at 16 countries in the European Union in 2007, revealed that the practice of HIA exerts a substantial influence on the decision making process, regarding the determinants of health.
According to the empirical evidence gathered from various countries which have implemented HIA, substantial support from the highest levels of government, in terms of administration and legislations, are major factors that influence the success of HIA. In addition, the stakeholders in Sri Lanka argue that political commitment is an essential condition when setting up HiAP.
A good regional example is the Government of Thailand. It enacted the National Health Act in 2007 with the aim of mainstreaming health in public policies. Following that, the National Health Commission and Health Impact Assessment was established in order to implement the aims and purposes of the Act. According to the Declaration of the National Health Commission in Thailand, any project or activity which has an impact on health has to obtain the HIA, prior to the commencement of the project or activity. Further, the Commission has held the National Health Assembly each year since 2008 to share the knowledge and experiences of other countries on their HiAP practices.
The Way Forward
It is evident that Sri Lanka currently does not have an integrated governance tool which deals with health in other public policies through policy formulation, implementation and evaluation at a national level. There are fragmented committees and task forces which address various health issues at different levels. However, it is observed that many government institutions, the private sector, NGOs, and civil societies, are not aware of the concept of HiAP and its importance for a healthy society. Hence, two main proposals were made at the stakeholder meeting to cement the commitment of these sectors, and to regularize the HIA in the country. Forming a sustained and effective governance tool should be the foremost objective of this initiative. To accomplish this, a series of effective advocacy programmes need to be conducted for wider groups of stakeholders from each sector, while the commitment of the political machinery needs to remain strong.
Finally, a legal window for regulating the HIA needs to be set up, in similar to the Environmental Impact Assessment, as it is the most effective governance tool for Healthy Public Policies in the country.
 A person with BMI between 25.0 and 29.9 is considered overweight and ≥30.0 is considered obese.
 Non-Communicable Disease in the South East Asia Region: Situation and Response, 2011, Regional office for South East Asia, World health Organization.
 Stahl Timo at el., Health in All Policies: Prospects and Potentials, Ministry of Social Affairs and Health 2006
Puska P.,(2007), Health in all policies, European Journal of Public Health, Vol. 17, No. 4, 328
 Kickbusch, I., Healthy Societies: addressing 21st century health challenges 2008
 David V. McQueen et al, Intersectoral Governance for Health in All Policies, Structures, actions and experiences,
World Health Organization 2012, on behalf of the European Observatory on Health Systems and Policies
 Personal communication with Dr. Sarath Samarage, National Consultant-WHO Country Office, Sri Lanka, and Former Deputy Director General/Planning and Country Coordinator, Secretariat for Social Determinant of Health, Sri Lanka.
 The chair of the committee was the Secretary of Health and the Secretaries of other relevant ministries were the members.
 The Ministers from the following ministries represented at the NHC: Ministers of Health, Higher Education, Finance and Planning, Labour, Rural Development, Housing and Construction, Home Affairs, Local Government, Agricultural Development and Research.
 Key functions of the NHC were: (1). to guide Ministries, departments and other organizations engaged in health activities; (2). to coordinate activities of Ministries and other organizations; (3). to create greater awareness among people of the importance of health; and (4).to promote community participation and involvement
 Round Table Discussion on Public Policies and its Impact on Health: Health in All Policies (HiAP), 21st February, 2012 at the Institute of Policy Studies
According to the WHO European Centre for Health Policy, 1999, pg. 4, HIA is “a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the
distribution of those effects within the population”
 Louise St-Pierre et al, Governance Tools and Framework for Health in All Policies, European Observatory on Health Systems and Policies.
 Wismar et al.,The Effectiveness of Health Impact Assessment, 2007, European Observatory on Health Systems and Policies.
 Thailand’s Rules and Procedures for the Health Impact Assessment of Public Policies, 2010, Health Impact Assessment Coordination Unit, National Health Commission Office, Thailand