Adelaide revisited: from healthy public policy to Health in All Policies
2007 Adelaide Thinker in Residence and Chair
of the Editorial Board
Chief Executive, Department of the Premier and
Cabinet, Government of South Australia
Chief Executive, Department of Health,
Government of South Australia
Increasingly countries are looking for mechanisms and strategies to implement a Health in All Policies Process. In the following, we give a short overview of the recent experiences in the State of South Australia—a process in which all three authors of this editorial were fully involved. These developments have led—20 years on—to a rediscovery and revisiting of the Adelaide Recommendations on Healthy Public Policy, adopted at the Second International Conference on Health Promotion in Adelaide in 1988 (WHO, 1988).
Health in All Policies is an innovative strategy that reflects the critical role that health plays in the economies and social life of 21st century societies. It introduces better health—improved population health outcomes—and closing the health gap as shared goals across all parts of government. It aims to address complex health challenges through an integrated policy response across portfolio boundaries. By incorporating a concern with health impacts into the policy development process of all sectors and agencies, it allows government to address the key determinants of health in a more systematic manner. It also takes into account the benefit of improved population health for the goals of other sectors.
This new approach has its antecedence in one of the 1986 Ottawa Charter's action strategies of ‘building healthy public policy’. The theme was explored in greater depth at the first follow up conference held in Adelaide, Australia in 1988. The Second International Conference on Health Promotion was organized to coincide with Australia's bicentenary and an invited audience of 240 participants attended from 42 mainly developed countries. The conference confirmed that equity and accountability were key issues for health (Svensson, 1988).
Public policies in all sectors influence the determinants of health and are a major vehicle for actions to reduce social and economic inequities, for example by ensuring equitable access to goods and services as well as health care. The Adelaide Recommendations on Healthy Public Policy called for a political commitment to health by all sectors (see below). Policy-makers in diverse agencies working at various levels (international, national regional and local) were urged to increase investments in health and to consider the impact of their decisions on health. Four priority areas for action were identified: supporting the health of women; improving food security, safety and nutrition; reducing tobacco and alcohol use; and creating supportive environments for health (WHO 1988).
| Adelaide Recommendations on Healthy Public Policy Extracts from the Second International Conference on Health Promotion in Adelaide, Australia (WHO, 1988). Healthy public policy is characterized by an explicit concern for health and equity in all areas of policy and by an accountability for health impact. The main aim of healthy public policy is to create a supportive environment to enable people to lead healthy lives. Such a policy makes healthy choices possible or easier for citizens. It makes social and physical environments health enhancing. In the pursuit of healthy public policy, government sectors concerned with agriculture, trade, education, industry and communications need to take into account health as an essential factor when formulating policy. These sectors should be accountable for the health consequences of their policy decisions. They should pay as much attention to health as to economic considerations.
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Early in February 2007, South Australia embarked on a program of activity to increase the understanding and commitment of all government agencies to Health in All Policies. This took place in the context of a commitment by government to whole-of-state strategic goals as set out in South Australia's Strategic Plan and to policy innovation more generally (website link below). One approach to bringing cutting edge thinking to the state is the Adelaide Thinkers in Residence programme (Government of South Australia, 2008a). This allows invited thinkers direct access to the Premier, Mike Rann, members of Cabinet and top level civil servants as well as other key players in South Australian society. In the first such residency with a health focus one of the authors of this editorial was invited as Thinker in Residence in 2007, with a brief to develop integrated policies and strategies around the broad theme of ‘Healthy Societies’.
The timing of the residency was fortunate because it could build its recommendations on a number of significant contextual factors both at the international level and within South Australia itself. A broad view of health policy had become prominent under the term ‘Health in all polices’ during the 2006 Finnish Presidency of the European Union and adopted by a conclusion by the Council of the European Union. The World Health Organization had embarked on a world wide process to engage governments to act on the social determinants of health. Indeed, Professor Fran Baum from South Australia is one of the members of the distinguished Commission that WHO has appointed for this purpose. South Australia had already embarked on important reforms to address pressing issues in health services reform, in particular a shift from hospital to primary health care and fundamental changes, through a ‘social inclusion’ initiative, to mental health services. The state can also boast a strong core of health professionals within and outside of government who are committed to equity and a social concept of health and health promotion.
The residency played the role of a catalyst for the South Australian Government's engagement in Health in All Policies and a first set of recommendations for action was issued by the thinker in March 2007. For these to be actioned high-level commitment from both the central government agency—the Department of Premier and Cabinet—and the Health Department was essential. The Chief Executives of these two key agencies—the co-authors of this editorial—gave clear signals of their support for government decision making to incorporate a Health in All Policies perspective. They too saw the Health in All Policies process as an innovation through which South Australia can further the commitment to joined up government which it has already spearheaded through South Australia's Strategic Plan or SASP (Government of South Australia, 2008b).
SASP outlines the values, priority areas and actions for the future directions of the state. The plan contains 98 targets (most of which have a 2014 deadline) relating to six major objectives. These cover the economy, environment, communities, wellbeing, education and innovation. SASP recognizes that the objectives and targets are part of an inter-related framework. The aim is to encourage both the collaboration and innovation required to address some of the most complex issues South Australia faces. The SASP therefore provided the obvious starting point for an integrated approach to policy coherence and informed policy-making necessary for Health in All Policies.
The residency proposed to apply a ‘health lens’ to SASP targets with the aim to address a two-way dynamic: how can better health support the achievement of the target and how does this target impact on health? The South Australian Department of Premier and Cabinet undertook a desk top analysis of the SASP examining the interconnections and synergies between a sample of targets across all six objective areas and their health impacts. A framework adapting the social determinants of health was developed and the available literature was scanned for both positive and negative health impacts, based on this framework.
Once published, the health lens analysis provided a mechanism for integration of health considerations across a wide range of policy areas that affect the social determinants of health such as the environment, education, child development, social capital, housing, transportation and employment. It identified relationships between sectors and stimulated further work by all sectors capturing the spirit of Health in All Policies. The health lens analysis helped policy and decision-makers outside the health sector to recognize these interconnections and appreciate the important role that non-health policies play in promoting health and the role better health plays in achieving other societal goals.
To provide an opportunity for the health lens analysis to move from theory to practice, the Government convened the Health in All Policies conference for 150 senior policy-makers in South Australia on the 21 November 2007. The Conference aimed to increase participants understanding of the key interactions and synergies between health, the economy and the achievement of South Australia's Strategic Plan (SASP) targets.
In the lead up to the conference a series of case studies were undertaken. The purpose of the case studies was to provide both an engagement strategy with key conference delegates and a policy learning opportunity where senior decision makers from across government participated in the development of Health in All Policies approaches to their targets. Seven targets were selected from the SASP health lens analysis and their impact on population health further explored. Stakeholders from across government were engaged in this process and worked towards identifying win–win solutions, where both population health was improved and progress would be made towards achieving their respective SASP target. The Conference provided senior officials from across government the opportunity to discuss the Health in All Policies concept and explore possible mechanisms to imbed it in to future government policy-making processes.
One of the key outcomes from the Health in All Policies Conference was the development of a set of core principles (see below). These principles articulate fundamental values to underpin a Health in All Policies approach and are a starting point for implementing them throughout South Australia's government. There was broad agreement from conference delegates that Health in All Policies is an important approach to include in future policy-making processes.
| Core Principles for Health in All Policies Developed from the South Australia Government's Health in All Policies Conference, 2007. A Health in All Policies approach reflects health as a shared goal of all of government. In particular it:
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Based on these outcomes and further recommendations from the Thinker in Residence, the South Australian Government is now considering how best to support the continued application of a Health in All Policies approach in pursuing the South Australia's Strategic Plan's targets. This includes developing effective ongoing governance mechanisms, building the capacity of all sectors to consider health impacts of their policies and expanding the technical skills of the health sector to support agencies to use Health in All Policies tools and processes. Other potential actions include experimenting in the application of this methodology to other portfolios such as education, considering issues such as gender and the health gap, and further expanding this process to include other actors, in particular local government.
The 21st century determinants of health and dynamics of the health society are challenging not only the way we conceptualize and locate health and conduct health policy but they also redefine who should be involved in policy-making. The experience in South Australia has shown that health is an exemplar of the interconnected policy making required in the 21st century. South Australia is now in a position to provide international leadership in the development of a Health in All Policies Model that strengthens the inter-sectorial approach required to build healthy public policy. It will seek to share these experiences as widely as possible. The Adelaide Recommendations on Health Public Policy have come ‘home’ in a very tangible way at their birth place.
References
Government of South Australia. Adelaide Thinker in Residence. (2008) a. www.thinkers.sa.gov.au.
Government of South Australia. South Australia's Strategic Plan. (2008) b. http://www.saplan.org.au/.
WHO. Second International Conference on Health Promotion. Adelaide Recommendations on Healthy Public Policy. (1988) http://www.who.int/hpr/archive/docs/adelaide.html.
Svensson P. G. (1988) The 2nd International Conference on Health Promotion: Healthy Public Policy, 5–9 April 1988: Adelaide Australia. 237–239. Health Promotion: An international Journal, 3.
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