Guest Blogger, Sebastián Peña Fajuri, is a Chilean medical doctor and an associate editor at the National Institute for Health and Welfare in Finland where he is currently working on a ‘Health in All Policies’ book for the Global Conference on Health Promotion in Helsinki 2013. In a series of posts, Sebastián will explore the health policy strategy of ‘Health in All Policies”. This first post introduces the concept and takes a historical look at why such an approach is important for the promotion of population health.
I must confess that before starting my current job at the National Institute for Health and Welfare in Finland, I was hardly aware of the growing high-level policy attention being given to the ‘Health in All Policies’ approach. Recently however, the World Health Assembly issued a strong call for its use and both the South Australian Government and the State of California in the United States have already started to implement it. It’s also one of four main themes in EU health policy.
Despite being presented as an innovation, the concept of Health in All policies is not new. It builds on the work of Geoffrey Rose and the Ottawa Charter from 1986, which promoted the concepts of “healthy public policies” and “intersectoral action for health”.
So, what is Health in All Policies?
Health in All Policies refers to a simple fact: areas other than health services have the greatest impact on people’s health. Our health depends more on what kind of work we have, where we live, what food is available to buy and so on.
Let’s take a classic example from Finland. Finnish men in the 1970s had the highest cardiovascular mortality in the world (around 720/100,000). In the peaceful eastern region of North Karelia, cardiovascular diseases were even more common. At that time, experts had a vague idea that these diseases were being caused by a high consumption of saturated fats, smoking and high blood pressure. The region, indeed, was a strong producer of butter, cream and other hearty milk products, as well as meat.
Together with the WHO, Finnish experts launched the North Karelia Project, knowing that in a region covered by snow half of the year and with limited productive capabilities; it wouldn’t be enough to inform the population of how to “eat better”. They had to look at the broader picture.
First, they started a broad communication campaign, focusing on community organizations and the training of peer-to-peer leaders. Taking it further, experts convinced local producers to reduce the fat content of local milk and sausages and to decrease the salt content in bread and pastries.
As a second step, local production, dominated by the dairy and meat industry, was reformed to include the production of rape seed oil and berries. The new products contributed further to reducing consumption of saturated fats. Experts also changed unhealthy consumption patterns at several other levels: introducing healthier school food and changing workplace menus.
A third element of the approach was the implementation of a legal framework. Finns issued a new Public Health law which emphasized health promotion and tightened tobacco legislation.
The North Karelia Project did not rely on pharmacological treatment nor focus on high-risk individuals; it focused on reducing overall risk within the population.
The intervention was a success: cardiovascular mortality decreased by 82%, a consequence of marked reductions in cholesterol levels, smoking prevalence and blood pressure. The project was later expanded to the whole country, which has experienced similar achievements.
The North Karelia Project is a success story on how to engage other sectors to improve health at a community level but it wasn’t until the Finnish EU presidency in 2006, that Finns launched the “Health in All Policies” strategy to promote successful intersectoral work, this time at a much higher policy level.
Health in all Policies provides a concrete roadway to strengthen global health promotion. In days that global health seems to be all about diseases (HIV/AIDS, malaria, tuberculosis) and health systems, it is important to dig into our closets for successful approaches. The lesson: take a deep breath, and go upstream.
Further reading
World Health Assembly. WHA62.14: Reducing health inequities through action on the social determinantsof health. 2009. WHO: Geneva.
Kickbusch I, Buckett K, editors. Implementing Health in All Policies: Adelaide 2010: Department of Health, Government of South Australia; 2010.
Health in All Policies Task Force. Health in All Policies Task Force: Report to the Strategic Growth Council. 2010.
Puska P, Vartiainen E, Laatikainen T, Jousilahti P, Paavola M. North Karelia Action: From North Karelia to National Action.
Puska P, Stahl T. Health in all policies-the Finnish initiative: background, principles, and current issues. Annu Rev Public Health, 2010. Apr 21;31: 315-28
In 1972 Finland responded to alarming heart disease mortality rates by launching on ambitious national demonstration teh North Karelia Project by pekka Puska. The aim was to implement a comprehensive, community-based programme to substantially reduce cardiovascular disease.
20 year results and experiences was presented in the first publication by
Puska P., Toumilehto J., Nissinen A., Vartiainen E.:
The North Karelia Project. National Public Health Institute of Finland, Helsinki 1995.
The second important publication was published in 2006:
Timo Stahl et al.: Health in All Policies-Prospects and potentials.
Ministry of Social Affairs and Health of Finland and European Observatory on Health System and Policies, Helsinki 2006.
Thanks Vera for the links!
What Finland did was brave and beautifully executed. On the bad side, it has, in my opinion, been difficult to change the focus to other more pressing needs of the Finnish society. E.g. health inequalities, functional capacity and work and health.
Intervention is really importnant. I wish we can do it here in UAE