Health Promotion International, 2016;31:888–898
doi: 10.1093/heapro/dav084
Advance Access Publication Date: 13 August 2015
Article
Health in All Policies in South Australia: what has
supported early implementation?
Toni Delany1,*, Angela Lawless1, Frances Baum1, Jennie Popay2,
Laura Jones1, Dennis McDermott3, Elizabeth Harris4, Danny Broderick5,
and Michael Marmot6
1
Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, SA 5001, Australia,
Institute for Health Research, Lancaster University, Lancaster, UK, 3Poche Centre, Flinders University,
Adelaide, SA, Australia, 4Centre for Primary Health Care and Equity, University of New South Wales,
Sydney, NSW, Australia, 5City of West Torrens, Adelaide, SA, Australia, and 6Institute for Health Equity,
University College London, London, UK
2
*Corresponding author. E-mail: toni.delany@flinders.edu.au
Summary
Health in All Policies (HiAP) is a policy development approach that facilitates intersectoral responses to
addressing the social determinants of health and health equity whilst, at the same time, contributing to
policy priorities across the various sectors of government. Given that different models of HiAP have
been implemented in at least 16 countries, there is increasing interest in how its effectiveness can be
optimized. Much of the existing literature on HiAP remains descriptive, however, and lacks critical,
empirically informed analyses of the elements that support implementation. Furthermore, literature
on HiAP, and intersectoral action more generally, provides little detail on the practical workings of policy collaborations. This paper contributes empirical findings from a multi-method study of HiAP implementation in South Australia (SA) between 2007 and 2013. It considers the views of public servants and
presents analysis of elements that have supported, and impeded, implementation of HiAP in SA. We
found that HiAP has been implemented in SA using a combination of interrelated elements. The operation of these elements has provided a strong foundation, which suggests the potential for HiAP
to extend beyond being an isolated strategy, to form a more integrated and systemic mechanism of
policy-making. We conclude with learnings from the SA experience of HiAP implementation to inform
the ongoing development and implementation of HiAP in SA and internationally.
Key words: Health in All Policies, health policy, equity, social determinants, intersectoral action
INTRODUCTION
Health in all Policies (HiAP) facilitates intersectoral relationships and policy development to address health and
equity issues while also contributing to other sectors’ policy goals. The intersectoral focus recognizes that health is
influenced by a wide range of factors such as housing,
employment and transport (Baum, 2008). HiAP sees
that promoting health will also assist in stimulating economic productivity and reduce the cost of health care
(Government of South Australia, 2011b). HiAP has now
been implemented in various forms in at least 16 countries
© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
Health in All Policies in South Australia
(Shankardass et al., 2011). As such, there is increasing
interest in how the effectiveness of the approach can be optimized (Kickbusch, 2008; World Health Organisation
and Ministry of Social Affairs and Health, 2013).
This interest has stimulated a growing body of international literature, which examines the enablers and barriers to HiAP work. Much of the literature consists of
commentaries or practice-based reflections, which draw
on the experiences of staff from organizations within the
health sector. The literature remains largely descriptive
and lacks critical, empirically informed analyses of the elements that support HiAP implementation (Shankardass
et al., 2012; Chircop et al., 2015; Shankardass et al.,
2014). Furthermore, literature on HiAP, and intersectoral
action more generally, provides little detail on the practical
workings of policy collaborations (Bryson et al., 2006;
Chircop et al., 2015). Despite these limitations, the existing literature provides insight into factors that may facilitate or impede HiAP implementation, which can inform
analysis of emerging empirical data within the field, particularly on the topics of trust, stakeholder involvement,
recognition of context and government funding.
Trust is identified as an essential element of effective intersectoral collaborations (Van Eyk and Baum, 2002;
Axelsson and Axelsson, 2006; van der Heiden, 2010;
Ogden et al., 2013; Rudolph et al., 2013a; World
Health Organisation, 2013). Maintaining trust within
partnerships through fulfilling commitments and maintaining open communication also assists in developing
credibility, which is another key facilitator of effective intersectoral work (van der Heiden, 2010; Leppo et al.,
2013; Leppo and Tangcharoensathien, 2013). Several
authors (Krech, 2010; Ollila, 2011; Rudolph, 2013;
Rudolph et al., 2013a) argue that to build and maintain
trust during the implementation of HiAP it is important
for the health sector to pursue transparent agendas and
share credit with collaborators.
Discussions within the literature also indicate that it is
important to involve collaborating sectors at each stage of
applying the HiAP approach to facilitate successful partnerships (World Health Organisation, 2011; Bostic et al.,
2012; Steenbakkers et al., 2012; Leppo et al., 2013;
Leppo and Tangcharoensathien, 2013). Rudolph et al.
(Rudolph et al., 2013a) recommend explicit discussions to
develop mutual goals at the beginning of the HiAP process,
ensuring all parties are able to identify shared benefits.
Understanding the particular institutional, policy and
political contexts that operate within the sectors that
collaborate under a HiAP approach is also imperative
to maintaining productive partnerships and relevant
outputs. Freiler et al. (Freiler et al., 2013) and Hendriks
et al. (Hendriks et al., 2013) suggest that this necessitates
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an approach where the focus and targets are framed to suit
the context within which the collaborating sector/s operates (Freiler et al. 2013; Hendriks et al. 2013). Such an approach also discourages ‘health imperialism’ where
problems and the necessary actions are defined from the
viewpoint of the health sector only (Nutbeam, 1994;
Howard and Gunther, 2012).
Political context has an impact on the HiAP approach.
In particular, short-term investment of resources can prevent adequate funding for sustained intersectoral work
(Bacigalupe et al., 2010; Ollila, 2011; McDaid, 2013;
Rudolph et al., 2013b). Bacigalupe et al. (Bacigalupe
et al., 2010) refers to the concept of ‘policy myopia’,
where politicians divert resources into policies that yield
short-term results, which will be realized while they are
still in office. This is due to the short-term nature of electoral terms, and the emphasis placed on maintaining political power, which several authors (Lin, 2010; Greaves and
Bialystok, 2011; Ollila, 2011) assert are not conducive to
supporting sustained intersectoral action that is intended
to stimulate long-term benefits.
Our findings build upon the literature in several ways.
The research contributes empirical and nuanced evidence
produced by capturing diverse public servant perspectives
across sectors. Within the paper, the complexities associated with establishing and satisfying shared intersectoral
goals are examined. The impact and politics of resourcing
are also considered in further depth through examination
of the views of those who participate in HiAP work in
the South Australian (SA) context. The paper describes
the interrelatedness of the elements that have underpinned implementation of the HiAP approach in the SA
context.
Background: the SA HiAP approach
HiAP was trialled and developed from 2007 in SA by the
Health Department and the central office of Government,
the Department of the Premier and Cabinet (DP&C), in
response to recommendations made by Adelaide Thinker
in Residence Ilona Kickbusch (Government of South
Australia, 2011b). As a cross government process it was
formally endorsed by State Cabinet in 2008.
A dedicated HiAP Unit was formed within the Health
Department to facilitate implementation. Between 2007
and 2013 this Unit grew from having one staff member to
six, and the staff worked with 13 different departments/
agencies during that time in various sectors, including the
environment, planning and transport sectors (Delany
et al., 2014a). In 2010, the Shadow Health Minister supported the widespread application of the HiAP approach
in many policy areas, implying bipartisan support (South
Australian House of Assembly, 2010).
T. Delany et al.
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HiAP work is linked to the agenda of the SA
Government, as expressed in the South Australian Strategic
Plan (SASP) (Government of South Australia, 2010a) and
the Seven Strategic Priorities of Cabinet (Government of
South Australia, 2011a). DP&C oversees implementation
of the HiAP approach, and has signed a memorandum of
understanding with the Health Department for joint governance of HiAP (Government of South Australia, 2010b;
Figure 1). Other defining features of the SA HiAP approach between 2007 and 2013 included working on
the basis of a co-operation strategy (Ollila, 2011) (often referred to as co-benefits) and use of a Health Lens Analysis
(HLA) process. The HLA process provided a mechanism
for examining the connections between policy and health
in a systematic and collaborative manner, which often resulted in evidence-based recommendations to guide policy
strategy (Lawless et al., 2012) (refer to Government of
South Australia 2011b; Baum et al., 2014; Delany et al.,
2014b for further information). HLA projects were jointly
funded by resources from the Health Department and the
collaborating departments/agencies. Figure 1 illustrates
the governance structure and the stages of the HLA process. The outputs that have been produced so far have varied depending on the particular foci of collaborations but
they have included literature reviews, reports, commissioned research to examine stakeholder perceptions and
an atlas of health status in particular communities.
These outputs have already had some impact on policy.
For example, the South Australian Numeracy and
Literacy Strategy 2013 drew directly on the collaboration
between Education and Health on a HLA project that investigated strategies for engaging parents in their children’s literacy development (Delany et al., 2014a).
METHODS
The data presented in this paper were collected during
the first 2 years of a 5 year research project that is
designed to address the question ‘Does a Health in All
Policies approach improve health equity and wellbeing?’
The research is focussed on the South Australian HiAP
approach and is underpinned by a critical action research framework (Baum et al., 2014). The methods
applied include in-depth interviews, workshops and
a survey [For further information about the research
refer to (http://www.flinders.edu.au/medicine/sites/
southgate/research/health-equity-and-policy/hiap.cfm)].
All data collection activities received prior approval
from the (Flinders University) Ethics Committee and
the SA Health Ethics Committee. The research is funded
by the Australian National Health and Medical Research
Council.
Fig. 1: SA HiAP Model 2007–2013 (Government of South Australia, 2011b).
Health in All Policies in South Australia
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Data collection and analyses
Interviews
Fifty-two individuals participated in a total of 70 semistructured, in-depth interviews between January 2013
and February 2014. These interviews involved public servants, four politicians and political staff members and
three academics who have had contact with the HiAP
approach since 2007.
This paper draws on a sub-set of the interviews to
examine the views of public servants working across
various sectors of the SA Government about the factors
that have facilitated and impeded HiAP in SA. Forty-five
public servants were interviewed (Table 1); 15 of these
people work within the Health sector and the remaining
30 work in the 13 Departments and Agencies that have
collaborated with Health on HiAP work. A total of 62
interviews were undertaken, with 12 public servants interviewed more than once (between two and four times)
given their roles in several HiAP projects, or the need to
capture information about developments over time.
Interviews were undertaken by six experienced academic
interviewers. Questioning was guided by a pre-prepared
interview schedule, as well by the flow of participants’
own narratives. The interviews were recorded and transcribed verbatim. The interviews averaged 55 min and
ranged from 15 min to 1 h 35 min.
Workshops
Two workshops were undertaken during mid-2013 to inform development of a theory-based programme logic
model designed to assist evaluation of the SA HiAP approach. The first workshop involved nine public servants
from five different Agencies that had collaborated with
Health as part of HiAP HLA projects. The second workshop was attended by 16 public servants from the SA
Health Department. Both workshops lasted 4.25 h.
Participants were asked about the factors that led to
HiAP being introduced in SA, the assumptions, activities
and processes that underpin HiAP implementation and
the short- and longer-term goals of HiAP work. There
were also frequent discussions about the context
Table 1: Positions of interviewees
Positions
Number of
interviewees
Chief executives or agency heads
Deputy chief executives
Other public servants ( policy officer to
director level, still working or retired)
Total
6
2
37
45
surrounding HiAP. The workshops were audio recorded
and transcribed verbatim.
Analysis of interview and workshop transcripts
Data collection and analysis proceeded simultaneously.
The research team conducted a collaborative, thematic
analysis of the interview and workshop transcripts using
the qualitative analysis software NVivo 10. Following
the initial round of open coding, which involved one
member of the team (T.D.) reading the transcripts to identify the central themes as well as collaborative coding
sessions involving several other team members, selective
coding (Ezzy, 2002) was applied to examine participants’
discussion of factors that facilitated and impeded HiAP
implementation in more depth. Concept mapping was
then undertaken to explore the relationships between the
themes and to move from description to explanation
through further team discussion and consultation of the
relevant literature.
Survey
During May and June 2013 public servants from many SA
Government Departments were invited to complete an online survey. The survey included 50 questions (13 of which
were open ended) to elicit information about respondents’
awareness of the HiAP approach, experiences of collaborating with HiAP work, perceptions about barriers and enablers to undertaking HiAP work, perceived outcomes of
HiAP work as well as respondents’ reflections on how the
social determinants of health and equity relate to the core
business of their departments. Three hundred and seventythree people were eligible for participation in the survey,
based on having had some contact with the HiAP approach between 2007 and 2013 and still working within
the Government at May 2013. One hundred and sixtyeight public servants responded to the survey and 128 answered all questions. Most respondents were from the
Health sector (40.7%); with 11.7% from DP&C, 9.8%
from the planning sector, 7.4% from communities and social inclusion and 6.2% from the education sector making
up the majority of the remaining participants. Forty per
cent of all respondents had been working within the SA
government for 20 years or more, and 29% had been
working in the Government for between 10 and 20
years. The participants had a range of roles in working
with HiAP, such as facilitating links between HiAP staff
and their own department/agency (39.9%), working on
a HLA project (27.7%) and supporting the development
of the HiAP approach or Unit in SA (27%). Length of
involvement with HiAP was spread relatively evenly between 1 and 5 years among respondents. Numerical
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data collected during the survey were analysed using SPSS
software to create tables showing the percentage of respondents who selected particular answers to each question. Cross tabs were also used to compare relationships
between responses to selected questions. Data from the
open ended questions was analysed thematically using
NVivo 10. Selected results relevant to the focus of this
paper are presented.
FINDINGS
This section presents key themes emerging from the analysis to explain the elements that have supported, and impeded, implementation of HiAP in SA. The supportive
elements of resourcing, trust, credibility and alignment
of policy priorities are discussed first. This is followed by
examination of impeding factors, including lack of support from some members of the policy community,
resource constraints and timeliness.
Factors that have supported implementation
in the South Australian context
The provision of a resourced, centrally mandated unit.
Resources. Participants identified multiple benefits associated with the provision of the dedicated HiAP Unit. It
provided a core group of staff who were resourced to
apply the HiAP approach. Partners on HiAP projects
viewed this dedicated resource as essential in progressing
HiAP work:
I don’t think any of this would have happened unless there
was a dedicated Unit and the resources to go with it . . .
we’ve thrown in a little bit of money that was available at
the end of the financial year but it could quite as easily have
gone to something else. It was the human resources within
the Unit that actually made it happen. (Workshop 1, senior
public servant from sector other than Health)
Another benefit was that the dedicated Unit employed
Health staff with a range of skills, both in maintaining collaborations and in identifying the potential health impacts
of proposed plans. These skills were identified as instrumental to project success, and often as complementary
to the diverse skill sets possessed by staff from collaborating sectors. The majority of survey respondents either
agreed (45.1%) or strongly agreed (12.3%) that collaboration with HiAP gives their department access to people
with different skills. This emerged as a key facilitator,
which has not been previously identified in literature on
HiAP.
Governance and mandate. The involvement of DP&C in
overseeing the HiAP approach was widely seen to support
T. Delany et al.
the entry of HiAP staff into departments across the
Government. It positioned HiAP as offering a ‘pool of
resources that can be accessed across Government’
(Workshop 2, public servant from Health).
Furthermore, Chief Executives from all Government
departments sit on committees that are facilitated by
DP&C. These committees have been established to drive
implementation of work across the Government under
key policy frameworks, such as the SA Strategic Plan
and the Seven Strategic Priorities of Cabinet. Several interview and workshop participants indicated that DP&C’s
involvement in overseeing HiAP, as well as HiAP’s alignment with these policy frameworks, increases the potential
for the HiAP approach to be discussed during committee
meetings, allowing collaboration opportunities to be identified and explored.
The joint governance structure of HiAP requires that
project proposals and final reports be signed off by senior
executives in Health and the collaborating departments,
and, often, by DP&C. This increased opportunities for
the exposure of key achievements at the senior level, thereby motivating partners’ collaboration:
one of the things in favour of participating in the HiAP
project was the fact that it was reporting up to a body
that I thought would have some influence for change.
(Workshop 1, public servant from sector other than
Health)
Appeal of the unit. Participants indicated that they were
motivated to engage with the HiAP Unit because it was
easier to work with than other parts of the Health
Department.
I’m not seeing a shift in the way that the Health
Department operates in terms of its relationship with
other parts of Government but the HiAP Unit does. So
in a sense it’s their positive interaction with us that really
is the – well, I’m not sure whether we’d call it a success yet
but I guess the ongoing goodwill that’s going on is because
of that Unit. (Workshop 1, senior public servant from
sector other than Health)
HiAP staff recognized the potential benefits of this and
purposefully framed their approach in a way that emphasized their connection to DP&C to facilitate their entry
into other departments.
we don’t talk about ourselves as being Health Department
people . . . so if we’re going to knock on a new door we’re
coming under the auspices of Department of the Premier
and Cabinet, because they’ve authorised us to act.
(Workshop 2, public servant from Health)
Health in All Policies in South Australia
Establishing and maintaining trust and credibility
Discussions of trust are woven throughout the data. Five
interviewees from departments other than Health admitted that they were initially sceptical of collaborating with
Health, because they were uncertain of the likely benefits
or the extent to which true collaboration, involving shared
agenda setting and fair work distribution, would be realized. Six participants from Health reported that they responded to collaborators’ initial uncertainty, as well as
their own unfamiliarity with other departments, by making efforts to build a relationship and learn about each
others’ work prior to planning the projects. This built
the acceptability (Shankardass et al. 2014) of the HiAP approach and developed relationships that would facilitate
the subsequent work.
I think after a while the trust built and [we realised] from a
cost benefit point of view for us the returns were good for
what we had to put in. (Workshop 1, senior public servant
from sector other than Health)
The interviews also revealed, however, that there is potential for trust and credibility to be lost within HiAP collaborations. Particular actions that were identified as
compromising this included collaborators failing to honour commitments, not establishing or maintaining clear
work plans and neglecting to uphold agreed processes of
group engagement and decision-making within working
groups.
Aligning HiAP with core business and strategic priorities
Participants frequently emphasized the importance of
HLA projects, and their anticipated outcomes, being
aligned with the core business agendas of all departments
involved, as well as the Governments’ broader strategic directions, policy and legislation, such as the SA Strategic
Plan, Cabinet Priorities and the SA Public Health Act.
Achieving such alignment was particularly important
within the political climate at the time of data collection
where there was high pressure to achieve savings and to
ensure that all expenditure was closely aligned with current priorities.
The Public Health Act and the public health planning process present opportunities to us of embedding HiAP type
processes as part of everyday business and building the
capacity of people to work in a partnership type way
with others because, quite frankly, we’re not going to
have the money anymore to achieve things through, you
know, buying the work of others if you like. (Interview,
senior public servant from Health)
Apart from justifying funding, aligning the focus of HiAP
work with the goals of collaborating departments and
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with the overall strategic objectives of the Government
also motivated intersectoral engagement.
Well, generally I guess common purpose facilitates it . . .
so there are obviously common agendas so you come together over that. (Interview, public servant from a sector
other than Health) Similar ideas were reflected in the survey data in response to open ended questions about what
factors encourage departments to collaborate with Health
and what worked well during the collaborations:
Alignment of strategic objectives and the commonality
of social factors that influence both education and health
outcomes.’ (2013 survey, senior public servant from sector
other than Health)
Working with HiAP provided an opportunity to align our
work to the Seven Strategic Priorities of Cabinet (2013
survey, public servant from sector other than Health).
Within the survey, workshop and interview data aligning
HiAP work with mutual goals and developing mutual
understandings about the work were identified as key
activities, and skills, of HiAP staff.
we had interactions with a different unit [within
Health] and we were getting nowhere because their headsets were different. There wasn’t an empathetic positioning from [that unit within] Health about what our
portfolios, drivers and concerns were so one couldn’t actually progress . . . what I think the Health in All Policies
team did was ‘let’s try and get into the heads of people
that work in a different policy space and work out from
that, see the areas of commonality’. (Workshop 1, senior
public servant from sector other than Health)
One of the ways HiAP staff have facilitated the development of mutual understanding and goals is by avoiding
the use of sector-specific language, while examining how
particular terms, such as equity and health, are defined
and understood in partnering departments.
. . . the challenge was really conceptualising our work in
the language of the other institution and vice versa . . . we
had to get our heads around different language and establish common ground about the use of language, but also
establish a stronger sense of understanding of each other’s
work and institutions and how they look, I think that was
a challenge for me . . . (Interview, public servant from
Health)
Threats to HiAP within the South Australian
context
Lack of support from some members of senior management
Despite the strong support provided by DP&C, as well as
the support garnered among policy staff, some senior
managers were less supportive of collaborating with
HiAP. Interview participants from four different
Departments reported unsupportive senior managers.
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This issue was also identified during the survey with
34.4% of survey respondents agreeing or strongly agreeing that they have concerns about how to justify collaborations with HiAP to senior managers. In response to the
open ended survey questions, difficulty in convincing
managers of the potential benefits of collaborating with
HiAP was linked to a persistence of siloed thinking
about core business, and the impact of this on structures
of accountability.
I think the main barrier for HiAP is lack of genuine commitment from senior management. This is because Chief
Executives are held accountable for their core business.
E.g. they have to report on how they are implementing
SASP targets they are directly responsible for. Implementing
HiAP is seen as an add on and not directly related (or at
all) to achieving the KPIs by which they live and die by.
HiAP is someone else’s KPI. (2013 survey, public servant
from sector other than Health)
Greaves and Bialystok (Greaves and Bialystok, 2011)
claim that such siloed thinking is inherent within governments, and that it can threaten the potential for, and of,
intersectoral partnerships. Our findings suggest that the
‘myopia’ referred to by Bacigalupe et al. (Bacigalupe
et al., 2010) encourages short-term thinking in departments, spurred on by a political focus on satisfying
department-specific performance indicators.
Resource constraints
Participants frequently raised concerns about the politically driven constrained fiscal environment and its potential
impact on future opportunities for intersectoral work.
Even participants who were positive about the benefits
of collaborating with HiAP felt that their capacity to do
so may be reduced in future. Over a quarter of the interview participants expressed dismay at regular and severe
funding cuts being made within their departments, based
on the rationale of achieving savings rather than on optimizing work processes or increasing eventual impact.
Survey respondents also reported high workloads within
which collaborative work could be considered to add
unnecessary pressure.
Currently there is a retreat to ‘core business’ and a narrower scope of health services. I think this removes the
mandate to work in this way. Also it takes time to build
awareness and partnerships and the staffing is lean and
workloads high! So this work harder to do’. (2013 survey,
public servant from Health)
Several interview participants viewed fiscal restraint as
a threat because it often stimulated a focus on narrowly
defined work to satisfy short-term imperatives. This is particularly relevant to HiAP because our findings indicate
T. Delany et al.
that, even within the Health sector, health promotion,
the pursuit of equity and future social improvement are
usually cast outside of definitions of what constitutes
core business given the dominance of short-term thinking
and narrowly focussed constructions of what constitutes
‘efficiency’.
. . . within a government climate where resources are
more and more scarce and budgets are tighter and tighter
the tendency will be always looking to where you can kind
of make efficiencies and somewhere like Health will be
really trying to be clear on what its focus is, and it’s really
going to be about hospitals and sick people I would imagine, so that then always would mean that areas like
Health in All Policies are always going to be a little bit
on the outer of that . . . it is a nice thing to do when you
have the resources in place to be able to do it. (Interview,
public servant from a sector other than Health)
Seven interview participants felt discouraged to continue
engagement with HiAP where, despite worthy strategies
being developed through the HiAP projects, they could
not envisage the work having any impact on the future actions of their Departments due to limited budgets.
. . . we did put up some ideas around creating some sort of
more system wide reforms, working with the sector a lot
more closely . . . but of course all of those things require
resources and I don’t think that we’re going to see them
anywhere in the future . . . I think you take your learning.
I’ve untied myself . . . (Interview, public servant from a
sector other than Health)
Duration of HLA projects
Approximately one quarter of interview participants discussed the length of time that HiAP’s HLA projects
took. Seven participants explained that they could understand why some stages of HLA projects took time to complete given complexities in working intersectorally, in
managing large collaborations and in attempting to navigate complex, hierarchical and frequently changing political and organizational environments. The amount of time
taken was interpreted by some participants as an asset that
enables people collaborating under the HiAP approach to
establish trust and to follow the work through to completion (depending on how completion is defined within a
given project, because the end point is tailored to the project). However, nine interview participants indicated that
HLA projects can be too lengthy, due in particular to staffing changes, increases in workloads across sectors and, in
some cases, a lack of clarity about the work plan. This
sometimes resulted in missed opportunities, particularly
if departmental or Government priorities shifted during
the course of the project work.
Health in All Policies in South Australia
When we drafted the initial report and recommendations,
I put them up to our Chief Executive and to our Minister.
They were happy with it, signed off, sent through. By the
time we came to actually then finalising that report, it was
months after. My Chief Executive then said ‘no, I’m not
signing off on this’. In that time the budget cuts had impacted. I think there is significant pressure on our
Department to find savings and the response from my
CE was ‘this isn’t core business. We’re not doing it’.
(Interview, public servant from a sector other than Health)
Frustrations over timeliness led several interview participants to reflect on how they believe future work could
be managed.
I would put a time limit on it and I would get involved
more to create more of a structure to our working group
rather than just letting things drift with everybody’s schedules. (Interview, public servant from a sector other than
Health)
[If we] suspect that the politics and the commitments
aren’t going to add up and we’re not going to achieve anything maybe it’s time to sort of say ‘well, you know we’ve
invested – we’ve agreed some things that haven’t happened. They’re not going to happen in the current political
environment so let’s put our effort somewhere else’.
(Interview, senior public servant from Health)
CONCLUSION AND PRINCIPLES TO INFORM
FUTURE HIAP PRACTICE
The empirical findings reported in this paper can inform
the future implementation of HiAP in SA, facilitating its
movement towards becoming a more embedded, and systemic, part of policy-making process. Figure 2 summarizes
the key elements that have supported HiAP
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implementation in SA between 2007 and 2013. It also
highlights the potential for development of an even stronger foundation for HiAP implementation through a focus
on garnering support, improving timeliness and devising
ways to emphasize the cost-effectiveness of HiAP outputs
across the Government.
The findings are also relevant to HiAP approaches in
international contexts. While it is important to consider
the role of specific political, cultural and geographic contexts when planning HiAP implementation, it is also possible to draw some generalizable principles from case
study research undertaken in specific contexts providing
that the research is developed through reliable and rigorous methods (Patton, 2002; Yin, 2014). Several such principles can be drawn from HiAP experience in SA.
Dedicating staff and adequate financial resources
is important for the HiAP approach to be feasible
The benefits arising from the provision of a dedicated
group of staff in SA highlight the importance of the provision of focussed resources—a factor highlighted in previous research that has shown that inadequate financial and
staffing resources have the potential to impede HiAP collaborations (van der Heiden, 2010; Ollila, 2011; Bostic
et al., 2012; McDaid, 2013; Rudolph et al., 2013a).
While it may not always be possible to dedicate a unit to
HiAP work, and while containing the work to a distinct
unit may have some impact on the broader integration
of HiAP across the Health sector, our findings indicate
that in SA the Unit was a valued resource, particularly
while the approach was being introduced across the
Government, and while collaborative relationships were
being established.
A central mandate is a key facilitator of HiAP
Fig. 2: Interrelated elements that have operated during the
implementation of HiAP in South Australia 2007–2013.
This research has confirmed that mandates for action from
the central agency of government facilitate implementation of, and departmental commitment to, HiAP. These
findings resonate with the existing literature (St-Pierre,
2009; Merkel, 2010; Gawith, 2012; Storm et al., 2013).
However, reflection on the SA experience makes clear
that mandates do not need to be used as what St-Pierre
(St-Pierre, 2009) calls ‘coercive measures’. Instead a central agency mandate can form part of an authorizing environment for HiAP, allowing collaborations to develop
more organically, with mutual learning and negotiation
rather than being forced. Legislative frameworks that
legitimize collaboration across government to work on
shared targets, such as the SA Strategic Plan, the State
Governments’ Seven Strategic Priorities and the SA
Public Health Act, add power to mandates from central
T. Delany et al.
896
government. In the South Australian context, the SA
Public Health Act was being developed during the early
implementation of HiAP and its architecture was informed
by HiAP principles. Now, it provides a legislative mandate
for HiAP and provides a range of mechanisms that may
allow HiAP approaches to be systematically adopted
across State and Local Governments, thereby, possibly,
increasing the scope and potential for HiAP work.
Collaborators require clearly defined timelines
and achievement milestones to support HiAP
feasibility
The findings reinforce existing research which indicates
that the appeal of participating in a HiAP partnership
may be diminished due to the long-term nature of the approach (Nutbeam, 1994; Leppo and Tangcharoensathien,
2013; Wagenaar and Burris, 2013). The current model of
establishing collaborative relationships applied within the
SA context can be lengthy and may, therefore, conflict
with the need to deliver outcomes that meet expectations
in a political context driven by siloed structures of accountability, short-term agendas and a focus on achieving
savings. Drawing on the strategies suggested by research
participants, these problems may be overcome by building
greater structure into the management of projects across
sectors and ensuring that all collaborators set aside time
in their schedules to dedicate to the project. It may also
be beneficial to build recognizable achievement milestones
into project timelines (Nutbeam, 1994). Achievement
milestones will provide ‘signposts’ that help collaborators
to recognize what the intended outcomes are during each
stage of the project, thereby facilitating continued engagement and enhancing clarity. Demonstrating progress towards each milestone may also help staff justify their
ongoing participation to senior management by providing
evidence of the mutual gains that are being achieved.
The dominance of siloed decision-making and
narrow definitions of core business threatens
HiAP success and reduces HiAP acceptance
Our findings draw attention to an enduring barrier to
HiAP: namely the current dominance of policy frameworks that focus the attention of senior decision-makers
on targets defined within the existing siloed structures of
government. In the SA context, the SA Strategic Plan
does facilitate intersectoral action to further progress towards targets; however, accountability for meeting targets
remains with single departments. This re-emphasizes the
importance of horizontal mechanisms that encourage
inter-agency partnerships and accountability across governments in the pursuit of shared societal, rather than
simply departmental, goals (Rudolph et al., 2013b).
However, if intersectoral collaboration towards achieving
long-term social improvement does not feature as a core
business goal this has the potential to threaten HiAP implementation. This is a recurrent theme in the literature
where it is evident that a climate of economic uncertainty
compounded by narrowly defined conceptions of core
business within public agencies is not one where policy
driven efforts to promote health and increase equity can
flourish (Baum et al., 2013).
ACKNOWLEDGEMENTS
We acknowledge the input of all Chief and Associate Investigators
who have contributed to the design of this research; Colin
MacDougall, Ilona Kickbusch, Kevin Buckett, Carmel Williams,
Sandy Pitcher, Andrew Stanley and Deborah Wildgoose. We
also acknowledge Gemma Prendergast for her work during the
Flinders Prevention, Promotion and Primary Health Care
Summer Research Scholarships Program in 2013–2014, where
she assisted in reviewing the international literature on Health in
All Policies. The views expressed in this paper do not necessarily
reflect those of the South Australian Government.
FUNDING
This work was supported by the National Health and Medical
Research Council (grant number 1027561).
REFERENCES
Axelsson R., Axelsson S. B. (2006) Integration and collaboration
in public health—a conceptual framework. The International
Journal of Health Planning and Management, 21, 75–88.
Bacigalupe A., Esnaola S., Martín U., Zuazagoitia J. (2010)
Learning lessons from past mistakes: how can health in all
policies fulfil its promises? Journal of Epidemiology and
Community Health, 64, 504–505.
Baum F. (2008) The New Public Health. Oxford University Press,
Adelaide.
Baum F., Freeman T., Jolley G., Lawless A., Bentley M., Vartto K.,
et al. (2013) Health promotion in Australian multidisciplinary primary health care services: case studies from
South Australia and the Northern Territory. Health
Promotion International. doi: 10.1093/heapro/dat029.
Baum F., Lawless A., Delany T., Macdougall C., Williams C.,
Broderick D., et al. (2014) Evaluation of health in all policies:
concept, theory and application. Health promotion
international, 29(suppl 1), i130–i142.
Bostic R. W., Thornton R. L., Rudd E. C., Sternthal M. J. (2012)
Health in all policies: the role of the US department of housing
and urban development and present and future challenges.
Health Affairs, 31, 2130–2137.
Health in All Policies in South Australia
Bryson J. M., Crosby B. C., Stone M. M. (2006) The design and
implementation of Cross‐Sector collaborations: propositions
from the literature. Public Administration Review, 66 (s1),
44–55.
Chircop A., Bassett R., Taylor E. (2015) Evidence on how to
practice intersectoral collaboration for health equity: A
scoping review. Critical Public Health, 25, 178–191.
Delany T., Baum F., Lawless A., MacDougall C., Harris E.,
McDermott D. (2014a) Creating a Burden of Evidence to
Consider the Impact of Health in All Policies: A program
Logic Approach, Montreal.
Delany T., Harris P., Williams C., Harris E., Baum F., Lawless A.,
et al. (2014b) Health impact assessment in New South Wales
& health in all policies in South Australia: differences, similarities and connections. BMC public health, 14, 699.
Ezzy D. (2002) Qualitative Analysis-Practice and Innovation.
Allen & Unwin, Sydney.
Freiler A., Muntaner C., Shankardass K., Mah C., Molnar A.,
Renahy E., et al. (2013) Glossary for the implementation of
Health in All Policies (HiAP). Journal of Epidemiology and
Community Health, doi:10.1136/jech-2013–202731.
Gawith L. (2012) Information Sheet 1: Background Information
on Health in All Policies (HiAP), Canterbury Health in All
Policies Partnership (CHIAPP).
Government of South Australia. (2010a) South Australia’s Strategic
Plan, Creating Opportunity. Vols 1 & 2. Government of South
Australia, Adelaide.
Government of South Australia. (2010b) The South Australian
Model of Health in All Policies. http://www.sahealth.sa.gov
.au/wps/wcm/connect/public+content/sa+health+internet/
health+reform/health+in+all+policies/the+south+australian
+model+of+health+in+all+policies (Retrieved 7 January
2013).
Government of South Australia. (2011a) Seven Strategic
Priorities. from http://saplan.org.au/pages/seven-strategicpriorities (Retrieved 23 April, 2012).
Government of South Australia. (2011b) The South Australian
Approach to Health in All Policies: Background and Practical
Guide, Version 2. Government of South Australia, Adelaide.
Greaves L. J., Bialystok L. R. (2011) Health in All Policies—all
talk and little action? Canadian Journal of Public Health,
102, 407–409.
Hendriks A.-M., Kremers S. P., Gubbels J. S., Raat H.,
de Vries N. K., Jansen M. W. (2013) Towards health in
All policies for childhood obesity prevention. Journal of
Obesity, 2013, doi: 10.1155/2013/632540.
Howard R., Gunther S. (2012) Health in All Policies: An EU
Literature Review 2006–2011 and Interview with Key
Stakeholders. Equity Action.
Kickbusch I. (2008) Adelaide revisited: from healthy public policy
to Health in All Policies. Health Promotion International, 23,
1–4.
Krech R. (2010) World Health Organization’s perspective on
Health in All Policies: challenges and opportunities.
Adelaide 2010—Health in All Policies International
Meeting. Adelaide, South Australia.
897
Lawless A., Williams C., Hurley C., Wildgoose D., Sawford A.,
Kickbusch I. (2012) Health in All Polices: evaluating the
South Australian approach to intersectoral action for health.
Canadian Journal of Public Health, 103(Suppl1), S15–S19.
Leppo K., Tangcharoensathien V. (2013) The health sector’s role
in HiAP. In Leppo K., Ollila E., Pena S., Wismar M., Cook S.
(eds), Health in All Policies: Seizing Opportunities,
Implementing Policies. Ministry of Social Affairs and
Health, Finland.
Leppo K., Ollila E., Peña S., Wismar M., Cook S. (2013) Health in
All Policies. Seizing Opportunities, Implementing Policies.
Ministry of Social Affairs and Health, Helsinki.
Lin V. (2010) Economic growth, economic decline and implications for Health in All Policies. Public Health Bulletin SA:
Health in All Policies Adelaide 2010 International Meeting,
7, 40–42.
McDaid D. (2013) Joint Budgeting: can it facilitate intersectoral
action? In McQueen D., Wismar M., Lin V., Jones C.,
Davies M. (eds), Intersectoral Governance for Health in All
Policies: Structures, Actions and Experiences. Spain, The
European Observatory on Health Systems and Policies.
Merkel B. (2010) European Union experience and perspectives.
Adelaide 2010—Health in All Policies International Meeting.
Adelaide, South Australia.
Nutbeam D. (1994) Inter-sectoral action for health: making it
work. Health Promotion International, 9, 143–144.
Ogden J., Morrison K., Hardee K. (2013) Social capital to
strengthen health policy and health systems. Health Policy
and Planning, 29, 1075–1085.
Ollila E. (2011) Health in All Policies: from rhetoric to action.
Scandinavian Journal of Public Health, 39 (suppl. 6),
11–18.
Patton M. (2002) Qualitative Research and Evaluation Methods.
Sage Publications, Thousand Oaks.
Rudolph L. (2013) Implementing Health in All Policies: Examples
and Lessons Learned. 141st APHA Annual Meeting
(November 2–November 6, 2013), APHA.
Rudolph L., Caplan J., Ben-Moshe K., Dillon L. (2013a) Health in
All Policies: A Guide for State and Local Governments.
American Public Health Association and Public Health
Institute, Washington, Oakland, DC, CA.
Rudolph L., Caplan J., Mitchell C., Ben-Moshe K., Dillon L.
(2013b) Health in All Policies: Improving Health Through
Intersectoral Collaboration, National Academy of Sciences.
Shankardass K., Solar O., Murphy K., Freiler A., Bobbili S.,
Bayoumi A., et al. (2011) Health in All Policies: A Snapshot
for Ontario, Results of A Realist-Informed Scoping Review of
the Literature. St Michael’s, Ontario.
Shankardass K., Solar O., Murphy K., Greaves L., O’Campo P.
(2012) A scoping review of intersectoral action for health
equity involving governments. International Journal of
Public Health, 57, 25–33.
Shankardass K., Renahy E., Muntaner C., O’Campo P. (2014)
Strengthening the implementation of Health in All Policies:
a methodology for realist explanatory case studies. Health
Policy and Planning, Advance Access, 1–12.
898
South Australian House of Assembly. (2010) South Australian
Public Health Bill. Hansard Recording, Wednesday 24
November.
St-Pierre L. (2009) Governance Tools and Framework for Health
in All Policies. National Collaborating Centre for Healthy
Public Policy, QC.
Steenbakkers M., Jansen M., Maarse H., de Vries N. (2012)
Challenging Health in All Policies, an action research study
in Dutch municipalities. Health Policy, 105, 288–295.
Storm I., Harting J., Stronks K., Schuit A. J. (2013) Measuring
stages of health in all policies on a local level: The applicability of a maturity model. Health Policy, 114, 183–191.
van der Heiden L. (2010) Health behind the dykes or health in
a lot of policies in the Netherlands. Adelaide 2010—Health
in All Policies International Meeting. Adelaide, South
Australia.
Van Eyk H., Baum F. (2002) Learning about interagency collaboration: trialling collaborative projects between hospitals and
T. Delany et al.
community health services. Health & Social Care in the
Community, 10, 262–269.
Wagenaar A., Burris S. (2013) Public Health Law Research:
Theory and Methods. Jossey-Bass, San Francisco.
World Health Organisation. (2011) Intersectoral Action on
Health: A Path for Policy-Makers to Implement Effective
and Sustainable Action on Health. Japan World Health
Organisation, Kobe City.
World Health Organisation. (2013) Learning from Intersectoral
Actions for Implementing Health in All Policies: a
compilation of case studies. http://isags-unasul.org/ismoodle/
isags/local/pdf/modulo6/collection_of-summaries_of_case_
studies_from_three_regional_projects.pdf.
World Health Organisation and Ministry of Social Affairs and
Health. (2013) 8th Global Conference on Health Promotion
Helsinki 2013. from http://www.healthpromotion2013.org/.
Yin R. K. (2014) Case Study Research: Design and Methods.
Sage, London.