Finding the mechanisms for governments to effectively consider health impacts across the policy spectrum has thus far proven elusive. In this research Dr Gemma Carey, Brad Crammond and Robyn Keast argue that the current mechanisms for cross government working are inappropriate or inadequate. Fortunately they also provide guidance on building the appropriate supportive architecture for change.
While there is broad agreement that addressing the social determinants of health is critical to health equity, the pathways to change remain elusive. Some researchers have argued that the gap between social determinants of health research, political action and policy trends is actually widening, despite this growing consensus.
The WHO has recommended that national governments adopt a ‘whole-of-government’ approach to address the social determinants of health, aimed at securing critical ‘upstream’ change (i.e. change within governments, which will result in widespread health benefits).
The necessity of including the whole of government in the effort to improve the social determinants of health has been recognised since Canada’s 1974 Lalonde Report (Lalonde, 1974). Similarly, the 1980 Black Report recommended the Cabinet Office machinery be made responsible for reducing health inequalities. Today, the model of government coordination sought by public health advocates has become more sophisticated but the central purpose remains the same: to have all relevant government departments included in all aspects of policy making and implementation on health inequalities.
Thus, regularly, those that advocate – in policy, research or practice – for the adoption of a social determinants of health gaze are arguing for changes in the way that government processes occur as much as they are arguing for specific changes to government policies. For example, Marmot and colleagues have recently argued for greater integration across government: “Reducing health inequalities is clearly a task for the whole of government, locally and nationally. However, too often action has been limited by organisational boundaries and siloes”.
There are two contemporary whole-of-government (or ‘joined-up government’) approaches currently being advocated for internationally: Health in All Policies (HiAP), and Marmot’s ‘fairness agenda’ (based on recommendations from the Marmot Review into Health Inequalities). You can read a full description of these initiatives here.
This is now a critical, but under-conceptualised, area of public health action. The design of these initiatives rely upon the same evidence that describes and documents the state of health inequities globally, despite their very different focus (i.e. government processes). A more relevant body of evidence would be successful whole-of-government intervention from disciplines like political science or public policy. This goes to the heart of current barriers to addressing the social determinants of health at a macro level.
We suggest that approaches to upstream change, like Health in All Policies, constitute a fundamentally different type of public health action that needs to be better theorised.
Rather than directly creating targeted policy action for improved health outcomes, these approaches aim to create changes in government processes which will indirectly benefit health through change in multiple policies. In our research, we refer to them as ‘instrumental process-based interventions’ (IPIs). We include the word ‘instrumental’ because these interventions are not proposed as being inherently able to improve health but rather that their implementation will be instrumental in the creation of healthier policy. They are also process-based, not simply in their focus upon government processes, but also because the interventions are usually constructed as introducing new decision-making processes and do not have explicit target policy outcomes. Finally, we refer to these processes as interventions following Hawe and Potvin’s definition of an intervention as to ‘come between’.
To help strengthen current IPIs (and inform the development of future ones), we conducted a meta-review of public policy research into similar policy interventions, drawing out characteristics associated with successful joined-up initiatives. We use this synthesis as a basis for comparing and contrasting emerging public health interventions concerned with joined-up action across government. The full review can be read here.
Overall, we found that the instruments used to create integration and collaboration across government are often inadequate or inappropriate. Two underlying factors have been identified that explain this shortcoming: (1) joined-up government interventions often lack a ‘supportive architecture’ that guides implementation and prevents them from washing out, and (2) there is often a fundamental mismatch between the goals they aim to achieve, the mechanisms used to achieve them and the level at which they are deployed.
The review challenges current assumptions about the best way to pursue a program of integrated change within government. In particular, we found that many of the standard instruments used to promote joined-up working – such as interdepartmental working groups – actually prohibit rather than facilitate collaboration and integration. Similarly, while current public health IPIs emphasise political commitment, IPIs that overemphasise high-level support become top-down and centralised, which significantly limits their effectiveness.
Perhaps the strongest lesson to emerge is the need for a robust ‘supportive architecture’, which must be based on a deep appreciation of the context and machinations of government. O’Flynn and colleagues warn that when seeking integrated policy change, a lack of attention to, and investment in, a supportive architecture will mean initiatives are doomed to fail, as the power of embedded ways of doing things restrains innovation and undermines cooperation”.
While we provide guidance on how to develop a supportive architecture to secure effective implementation of public health IPIs, we also argue that to progress the goal of health equity more collaborative research is needed with public policy researchers. As MacCathaigh and Boyle lament, “we still have too little joined up thinking about joined-up government”.