Chapter 11 Developing healthy public policy

Overview

Healthy public policy (HPP) was identified in the Ottawa Charter (World Health Organization (WHO) 1986) as one of the five key strategies for promoting health. HPP focuses on changing the environment in order to make the healthy choice easier. Health is affected by many different policy areas:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control (Universal Declaration of Human Rights Article 25(1)).

HPP therefore includes all the major areas of policy that are the responsibility of democratic governments – employment, welfare, education, transport, food and health and social services. Relevant policies may also be instigated by private commercial organizations or devolved government agencies. Promoting HPP across this range of agencies and issues appears to be a daunting task. How to make inroads into this aspect of health promotion is the subject of this chapter, which examines the infrastructure required to facilitate HPP, the role of the practitioner and the potential of this approach to promote health. Readers are referred to Chapter 4 of our companion volume (Naidoo & Wills 2005) for a more detailed discussion of the policy process.

Defining HPP

Policy is a contested term, with meanings ranging from intentions to decisions and strategies. Milio (2001, p. 622) in a glossary of definitions describes it as ‘a guide to action to change what would otherwise occur, a decision about amounts and allocations of resources: the overall amount is a statement of commitment to certain areas of concern; the distribution of the amount shows the priorities of decision makers. Policy sets priorities and guides resource allocation’. We shall adopt a broad definition of policy as a plan of action to guide decisions and actions. Policy can be developed and implemented at many different levels, from organizational to national to international. Whilst policy may be allocated to a specific sphere, such as health, education or transport, in practice its effects are often wide-ranging and extend beyond the sphere originally targeted. Figure 8.3 in Chapter 8 illustrates the many agencies and organizations that promote health in some way. At government level the Treasury, for example, tries to influence individual behaviour through taxation of unhealthy products whilst the Department of Children, Schools and Families tries to do this through school-based health education. Joined-up policy-making is the term used to refer to integrated policy-making across different spheres. The determinants of health are multiple and interconnected, so in order to be effective, policy also needs to be holistic. It is often assumed that policy, once made and adopted by the relevant agency, translates smoothly into the intended action and anticipated outcomes. However this is the exception rather than the rule. Policy is (re)interpreted at all levels and its practical application may diverge from the original intention. It is therefore not enough to make policy; it must be followed through, monitored and supported by appropriate training and resources.

WHO has defined HPP as: ‘placing health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health’ (WHO 1986, p. 2). This is a very broad definition, as is the Ottawa Charter’s (WHO 1986) definition of HPP as a central plank for health promotion. The Ottawa Charter cited the following fundamental resources for health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. This embraces all governmental activities, except, ironically enough, the provision of health services, although they might be counted as part of the social justice and equity resources. The Second International Conference on Health Promotion in Adelaide, Australia in 1988 (WHO 1988) explored HPP. It called for a political commitment to health by all sectors and an explicit accountability for health impacts.

Further international conferences focused on the globalization of health and the need for international cooperation to tackle the determinants of health. The Sundsvall Conference concentrated on the global, interlinked nature of environmental change to promote health (WHO 1991). The Jakarta Declaration (WHO 1997) and the Mexico conference (WHO 2000a) focused on the interlinked nature of social, economic and political development for health. The Bangkok Charter (WHO 2005) sought to make health promotion central to the global development agenda, and called for commitments from governments, communities and the private corporate sector to address health determinants and reduce inequalities.

BOX 11.1

Are there any core values that should underpin HPP? If so, what are they?

Some core values underpinning HPP may be inferred from the conferences and charters outlined above and are also discussed in Chapter 4. These include:

• Equity – an active redistribution of the material resources required for healthy living, e.g. income, housing

• Upstream focus – concentrating on the socioeconomic determinants of health rather than individual lifestyles

• Participation – the involvement of all interested partners including governments, practitioners and the public

• Collaboration – working across organizational and national boundaries to meet agreed goals

• Sustainability – meeting existing needs without compromising the ability of future generations to meet their own needs.

What is clear from the above definitions resulting from the WHO international conferences is the broad scope of HPP, encompassing as it does all levels of government from international to national to local.

No policy would claim to have adverse health effects and most would claim to increase well-being in some way, albeit indirectly. Yet many policies may have apparently contradictory effects. For example, it has been argued that the overall economic effect of a reduction in smoking would be negative, due to the loss of tobacco tax revenue to the exchequer, and the extra demand on services due to people living longer. Economic policies that increase the income of the wealthiest have been defended on the grounds that there would be a ‘trickle-down’ effect, despite evidence that increases in relative inequality are detrimental to health (Wilkinson 1996). The application of stringent animal and environmental welfare regulations in the UK has resulted in an increase in meat imports from other countries where the same regulations do not apply. The consequences of policy programmes therefore need to be thought through in some detail. Health impact assessment (HIA) is an approach that does just this. HIA enables the identification, prediction and evaluation of likely changes to health, both now and in the future, as a consequence of a policy programme or plan. HIA recognizes that health is affected by a broad range of determinants linked in various pathways. For example, a HIA of a policy to extend licensing hours would weigh up the benefits and disadvantages of the proposal’s impact on individuals, the local community, the environment and the economy. Whilst the proposal may benefit the local economy, disadvantages to health, law and safety, and community cohesion are likely.

HIA as an approach is likely to become more widespread as various international agreements require an assessment be made of the likely impact of policy. For example, the European Union requires the establishment of mechanisms to ensure a high level of human health protection in the definition and implementation of all Community policies and activities (article 152 of the Treaty of Rome).

BOX 11.2

Health impact assessments in London

Hosting the Olympic Games

Hosting the 2012 Olympic Games in London is anticipated to bring economic benefits to local communities. It might be assumed that the construction of additional sporting facilities will improve the opportunities for physical activity amongst the local population. However this is not necessarily the case. The extent to which members of a community will use facilities and opportunities is almost impossible to quantify in advance. There may also be an adverse health impact (e.g. air and noise pollution) on the community during the construction phase. A rapid HIA concluded that the overall impact will be positive: ‘there will be greater benefits to the local communities arising from increased employment and income opportunities, greater physical activity and enhanced community cohesion’ (http://www.londonshealth.gov.uk/PDF/Olympic_HIA.pdf).

The history of HPP

HPP has a long and illustrious history. Many would date its origins in the UK to the 19th century and the rise of the Sanitary Reform Movement, prompted by concerns about the spread of disease in overcrowded industrial slums. Edwin Chadwick’s Report from the Poor Law Commissioners on an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain (1842) made it clear that the poor did not have the power to change their conditions, and that protecting and promoting their health were tasks of local government. The 19th century saw a plethora of legislation and regulations to protect and promote health – a trend that was carried on into the 20th and 21st centuries (see Example 11.3).

BOX 11.3

Landmarks in healthy public policy in the UK during the 19th, 20th and 21st centuries

1842 Edwin Chadwick’s Report from the Poor Law Commissioners on an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain is published

1843 The Royal Commission on the Health of Towns is established

1844 The Health of Towns Association is founded

1845 Final report from the Royal Commission on the Health of Towns is published

1848 Public Health Act for England and Wales requires local authorities to provide clean water supplies and hygienic sewage disposal systems, and introduces the appointment of medical officers of health for towns

1854 John Snow controls a cholera outbreak in London by removing a contaminated local water supply

1866 Sanitary Act – local authorities had to inspect their district

1868 Housing Act – local authorities could ensure owners kept their properties in good repair

1871 Local Government Board (which became the Ministry of Health in 1919) was established

1872 Public Health Act makes medical officers of health mandatory for each district

1875 Public Health Act consolidates earlier legislation and the tone changes from allowing to requiring local authorities to take public health measures

1906 Education Act establishes the provision of school dinners

1907 Education Act establishes the school medical service. Notification of Births Act and the development of health visiting is encouraged