This post was originally published on the Bill of Health blog of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School. The post is part of a symposium from speakers and participants of Northeastern University School of Law’s annual health law conference, Diseases of Despair: The Role of Policy and Law, organized by the Center for Health Policy and Law. All the posts in the series are available at Bill of Health, the blog of the Petrie-Flom Center for Health Law, Biotechnology, and Bioethics at Harvard Law School.

By Peter D. Jacobson

Scholars and public health advocates have expressed optimism about the potential for Health in All Policies (HiAP) initiatives to improve both health equity and population health. HiAP is a collaborative approach across all sectors, involving both public and private decision-makers, to integrate health and equity during the development, implementation, and evaluation of policies and services. Braveman and colleagues define health equity to mean that “that everyone has a fair and just opportunity to be as healthy as possible.”

I suspect the vast majority of health law scholars support the concept of health equity. But what does the concept mean in practice and how can it be implemented? From a public health law perspective, does implementation require a legal imprimatur or can it be effectively designed and implemented absent some sort of legal mandate?

To understand whether academic and advocacy enthusiasm for these programs is warranted based on the available evidence to date, Rick Hall and I conducted an empirical study of health equity/health in all policies (HiAP) programs. Initially, I was skeptical that these programs would justify the advocates’ expectations. After all, it’s just one in a long line of fads to dominate health and public health policy. But based on the interviews, I now believe that HiAP initiatives are desirable as an organizing principle and the focus on health equity is a policy imperative. Here’s why.

Overview of the Study

We conducted 71 case study interviews in 5 states and 14 localities with existing HiAP/health equity programs to examine how HiAPs are developed, structured, and implemented. The interview protocol probed:

  1. HiAP formation (i.e., governance structure);
  2. Program goals and measurement;
  3. Inter-sectorial coalition-building strategy;
  4. Internal and external barriers to successful implementation;
  5. The role of health equity considerations; and
  6. Policy and practice changes that have been achieved, focusing on those already underway.

We found a relationship between the use of a HiAP approach and the prominence of health equity as a policy concern. In emphasizing the social determinants of health, HiAP gives public officials and policy entrepreneurs a framework for promoting this goal. In several sites, we found a gradual transition in focus from health generally to health equity. At the same time, the connection between HiAP and health equity is variable; the connection is usually organized around specific issues.

We also found that while a formal legal mandate is useful, respondents did not require it to develop and implement their health equity agenda. Instead, they did so through informal social networks that expanded over time.

Our results suggest that HiAP is useful as an organizing principle by providing a framework around which multiple stakeholders can operate. The successful HiAP efforts start small, based on bilateral interpersonal relationships, demonstrate proof of concept to other governmental agencies and community organizations, and then expand to multilateral collaborations. In particular, initial success leads to joint grantmaking efforts. But implementation is a long process. In our case studies, there were only limited data to demonstrate how these initiatives have improved health equity or reduced health disparities.

Framing HiAP initiatives in equity terms tends to be strategic and selective. Health officials anticipate and adapt to the incentives and constraints created by other institutional actors, which has lessons for other policy actors in applying the HiAP/health equity approach. Respondents noted that in working across sectors it is important for public health practitioners to avoid public health imperialism.

The Politics of HiAP/Health Equity

Not surprisingly, we anticipated that politics would play a key role in the HiAP/health equity process. And it did, but not entirely in the way we expected. The most significant political aspect of the interviews was the stark recognition that health equity needed to be discussed differently within a given state or locality.

Because politically conservative areas are more skeptical about health equity, this limits diffusion across political environments (even within some counties). As a Chief Health Officer in California noted, HiAP/health equity “Must be adapted to local problems and framed to address people who are not already committed. No concerns about the ideas—only about the politics.”

As a result, proponents of HiAP/health equity need to develop a different political strategy for each group or community.

HiAP/Health Equity and Public Health Law

Two aspects of the study are relevant to health law and public health law. The first, as mentioned earlier, is whether a legal imprimatur is necessary. The second is whether state and local health officials can use the public health code to develop and implement HiAP/health equity programs.

At the outset, I expected that a formal legal imprimatur, anything from a gubernatorial proclamation to legislation, would be an essential impetus for HiAP/health equity initiatives. And it’s fair to say that the Governor’s proclamation forming the California HiAP Task Force has been an important catalyst for its efforts. But while a formal legal mandate might be useful, our results suggest that it’s not necessary. We found several ongoing HiAP/health equity initiatives that started without any legal endorsement. Of these, private foundations were the most important catalysts. At this point, it remains uncertain whether those initiatives starting with a legal mandate will be more sustainable than those without one.

As for the second issue, the public health code can be useful, but is also not a necessary precondition. Absent separate legal authority, public health codes are neutral regarding HiAP/health equity—they neither facilitate nor impede program development and implementation. For health departments, the issue is balancing limited resources with meeting mandatory services requirements to protect the public’s health.

One can easily argue that achieving health equity is a core public health value that should infuse all programs. In reality, as suggested above, using health equity as a program lens, though highly desirable, entails political tradeoffs that must be navigated. One way or the other, political support is a necessary condition for robust HIAP/health equity initiatives.

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