Health in All Policies: The emperor’s old clothes

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

10 thoughts on “Health in All Policies: The emperor’s old clothes

  1. 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.

  2. 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.

  3. I love this. I think we all know it. Interventions directed at the health sector alone do not work. The story of TB in the industrialized a good case in point . Tuberculosis rates plummeted as the socio -econimic conditions of the population improved and long before chemotherapy became available. It is time we woke up to this fact and do something about it.

  4. Hi Sebastian – of course there are plenty of great examples – here are two.

    In the UK I think a really interesting initiative are the development of commissions at municipality level – my blog draws together 4 examples –

    Its also worth keeping an eye on the Equity Action Website – this is a programme pulling together the work of 16 EU Member States on the Social Determinants of Health –

  5. I agree that the SDH provide an important-even obvious- link to the health in All Policies. Given that they are both supported by WHO what efforts are being made at WHO HQ to bring these together ?

  6. Treating injuries and disease is an entirely different focus than the prevention of such. My company has been in the business of preventing workplace musculoskeletal disorders for 20 years. In our initial research we were stunned at the lack of the personal knowledge, held by almost 100% of US population (and Canadian and Australian), of the basic anatomy and functions of the spine-as it pertains to everyday activities of daily living. Lacking this knowledge puts every person at risk of experiencing unnecessary micro-traumas every day of their lives. Over the last 20 years and now with over a million people trained there have been countless surgeries prevented and significant financial savings at many organizations of all descriptions. We have discovered that people are extremely eager to learn how they can be more in control of whether or not they will incur a painful sprain/strain injury. AND most importantly that when taught properly they will change their behaviors accordingly. Preventing injury and disease is the purview of individuals not institutions. People just need to become aware of how to do so. Most people are sufficiently motivated to live for pleasure and to avert pain. These are the individuals that will embrace health and wellness solutions. How to teach people is the art and the secret to broad success. This is what much of our refined research went into. How to get people to change their physical behaviors to better protect their own well-being. It is a vastly rewarding profession!!

  7. I agree!

    And, I was going to leave it at that.

    Until I read –

    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”.

    And, writing *from* Ottawa, I felt that it behooved me to say more.

    And, there are oh!-so many different avenues of thought to which I could lend my support:

    – emperor’s new / old clothes
    – there is nothing new under the sun
    – everything that I needed to know in life, I learned in kindergarten
    – &c

    I think that a good starting point for all is to *believe* the WHO definition of health – it, too, is not new – in fact, it predates by decades, the Ottawa Charter –

    Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

    [Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. The Definition has not been amended since 1948.

    Everything else follows from that –
    – mutual respect
    – mutual aid
    – decency in food, water, accommodation, working
    – infrastructure
    – systems – education, disease treatment, &c
    – &c

  8. Very good example of intesectoral coordination for health. Thank you very much for your interesting sharing.

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