Health in All Policies in the Pacific

Abstract

Health in All Policies is an approach that seeks to strengthen public policy‐making across health and other sectors in order to achieve the most favourable health impacts. There is currently interest in understanding how Health in All Policies is applied in different contexts; whether it makes a difference to policy practices, health outcomes and health equity; and what is required to equip the different sectors to work effectively to improve the health equity impacts of their policies. This article presents findings from a review of domestic policies and practices of Health in All Policies in countries across the World Health Organization Western Pacific Region. The findings illustrate that there is a strong foundation for action, particularly given prior intersectoral action and the important convening point that issues like non‐communicable diseases and transport provide for Health in All Policies within the Western Pacific Region. However, the consideration of health equity in Health in All Policies needs more explicit attention. This knowledge can be used for building capacity within the health sector and other sectors to undertake sustainable and effective intersectoral collaboration for improved health equity.

1.

Introduction

The Western Pacific Region is home to almost 25 per cent of the world's population (approximately 1.8 billion people). Using the World Health Organization (WHO) regional classifications, there are 37 countries and areas in the region (WPRO ), which span all stages of economic development. There have been dramatic improvements in life expectancy and premature mortality across the region in the past couple of decades (Figure  ). However, these improvements are not distributed equally between countries or indeed between social groups within countries. For example, the prevalence rate of HIV/AIDS in Papua New Guinea is nine times the rate in the other countries across the region, and the prevalence of tuberculosis in countries such as the Lao People's Democratic Republic is four times the prevalence in the high income countries. Non‐communicable diseases (NCDs), such as heart disease, diabetes and injuries, also play a major part in the overall disease burden and mortality rates in many countries in the region (AP‐HealthGAEN ).

Adult mortality risk among males and females in select countries in the Western Pacific Region, 1970–2010 Note: 45q15 represents the probability that an individual who has just turned 15 years will die before reaching the age of 60 years, on the assumption that the age‐specific mortality conditions of the year are constant throughout life.Source: Rajaratnam et al. ().

Health inequity is the systematic, unfair and avoidable differences in health status. These inequities, observed across the Western Pacific Region, can be influenced by the actions of society in general and government in particular. In 2008, the WHO Commission on Social Determinants of Health highlighted the unfair differences in daily circumstances in which people are born, grow, live, work and age, and how these affect health inequities within and between countries. The Commission demonstrated how economic and social policies generate and distribute political power, income, goods and services. It noted that these are distributed unequally, meaning that different social groups have different exposure to, for example, quality health care and education, sufficient nutritious food, conditions of work and leisure, and quality of housing and built environment—all matters of public policy. Together, these structural factors and daily living conditions constitute the determinants of health inequities (CSDH ).

Health in All Policies (HiAP) was one strategy recommended by the Commission to address the social determinants of health inequity, by aiming to include health and health equity considerations in domestic policy‐making across different sectors that influence health. HiAP is not new. It has its roots in the early history of public health and later with ‘healthy public policy’, first coined as a term in the late 1980s (Milio ) and building on earlier approaches to intersectoral action (ISA) for health.

The way in which the social drivers of health inequities play out and the degree to which action is taken to address health inequities vary greatly between different political, social and cultural contexts and regions. These questions prompted the WHO to commission a review of regional practices of HiAP (including the Western Pacific) to support assessments of opportunities for and learning from practice on how to implement HiAP (Friel et al. ; WHO ) in 2012.

This article aims to analyse how the globalised concept of HiAP is being applied using an exclusively Western Pacific lens. Very early in the review process, it became clear that in practice HiAP and ISA are used interchangeably in many instances in the literature and current action across the region. It was decided therefore to include both. The article begins by describing the methods used to collate and synthesise the evidence relating to HiAP and ISA for health across the region and the results focus on three areas: (i) a description of the environment across the region and how conducive it is to HiAP; (ii) an explanation of why and how HiAP approaches have been implemented to address the social determinants of health, and where possible to identify what difference they have made to health and health equity, and (iii) the issue of equity, describing the design of ISA that has equity as an explicit target or outcome and the main approaches used to address equity. The article concludes by suggesting what is needed to build and sustain HiAP or ISA across the region, including the structural barriers and facilitators of HiAP or ISA, the knowledge and skills needed, ways of measuring success and the central elements of effective HiAP or ISA.

2.

Methods

2.1

Analytical Framework

An analytical framework developed by colleagues in the WHO headquarters was used to guide collection and assessment of identified examples of HiAP and also ISA from the region (WHO ). The framework aided the systematic categorisation of HiAP examples, including key aspects such as the relationships between actors, mechanisms for distributing decision‐making across the government, the role of stakeholders, and the intent and capacity to address health equity. The framework sought to facilitate the development of a common set of concepts underpinning HiAP and ISA, providing a systematic way to interrogate how policy‐makers think about intersectoral problems and solutions for health. The framework has four main components:

1. Opportunities for initiation refers to the socioeconomic and historical contexts, and the potential for HiAP, emphasising the policy change window (national or local context) and the role played by international influences.
2. Key drivers of implementation covers the factors shaping the type of implementation (i.e. who the actors are and what they are doing) and helps identify the capacity and limitations with implementing HiAP.
3. Key drivers of an equity lens given that the overall exercise sought to better understand if and how HiAP addressed equity issues by assessing examples in terms of intent, the universality of the approach and whether explicitly stated goals to address equity exist.
4. Key drivers of sustainability includes factors that help shape the continued roll‐out of action once there is commitment to a HiAP approach.

2.2

Data Collection

A qualitative mixed methodology design was used for this analysis. The analytical framework was populated using (i) a systematic review of peer‐reviewed journal articles and grey literature related to concepts, actions and cases on how HiAP and ISA is or could be implemented, (ii) key informant interviews with policy‐makers and practitioners involved in HiAP and ISA in countries across the region, and (iii) a further review and analysis of grey and peer‐reviewed literature to elaborate detailed examples (case studies) identified through the first two processes to highlight key aspects of relevance to HiAP and ISA.

• (i) 

  Literature review: 

  The literature search was undertaken centrally by colleagues at the WHO headquarters using the search criteria developed to apply to each WHO region. Eighty‐seven peer‐reviewed papers were identified and 38 were used. Fourteen pieces (Cambodia, China, Hong Kong (China), Malaysia, Mongolia and the Republic of Korea) were identified as relevant from the database of grey literature provided by the WHO. The evidence does not come equally from all parts of the region because in some areas information does not exist or has not been published.

• (ii) 

  Key informant interviews: 

  Telephone interviews were conducted with senior policy‐makers in health and other sectors to gain a better understanding of the mechanisms that facilitate the initiation of intersectoral initiatives, plus the mechanisms that give or could give sustainability to intersectoral work, including structures of government, levels of decentralisation, and the relationships and power between different sectors of government. Six telephone interviews were undertaken: four of the six interviewees were senior policy‐makers in either national or state level health departments, and two interviewees were from other sectors, one at the national government level and the other at the regional or state level.

• (iii) 

  Case studies: 

  Through the first two steps, three examples of action were identified that were developed as case studies (helmet law in Viet Nam, HiAP approach in South Australia and the NCD Emergency Declaration in Palau). In each case study, we describe the level of action; sectors involved; relevance to HiAP; issues addressed by the activity; overview of the activities and processes; associated monitoring and evaluation; overview of the country context; and limitations and assumptions (see the Supporting Information Appendix S1 for full details).

3.

Results

3.1

An Environment Conducive to Action on the Social Determinants of Health and Health Equity in the Western Pacific Region

Entry Points

Both the grey literature and the interviews identified the importance of the current NCD crisis as a major entry point for ISA. Other entry points for ISA identified in the literature were cancer, child abuse surveillance, natural disasters, nutrition, public health education, sexual health, technological development and women's health. Other issues identified included maintaining mosquito control as malaria decreases in some countries; agricultural bio‐diversity (Qingwen et al. ), ISA on health equity in urban policies (WHO Centre for Health Development ); and a healthy city initiative (Gumi City Public Health Center and Kyungpook National University School of Medicine ).

Political Will

Political will to enable ISA is emphasised in several articles (Yadav ; Yip & Anderson ) and reflected in the interviews with senior policy‐makers. Each interviewee noted the importance of having calls for ISA at the regional level, partly because it reinforced the mandate for ISA or HiAP approaches in the home country. Being able to demonstrate that their own country was aligned with international movements was important to build pride in action domestically. Also, membership of cross‐country initiatives or ministerial meetings helped push countries to be accountable for their actions to address the social determinants, therefore promoting HiAP action within the country.

This has been quite important for us. Most of us work on the statements and recommendations from the Pacific Island Ministers for Health Forum. … Leadership and guidance [from the other countries] is helpful not only for our Minister but for guiding our policy and programs.

The interviewees reported that political leadership and engagement within countries around ISA was very important to effect action and change. For example, in South Australia, many of the earliest HiAP strategies were initiated by the State Premier, and in Palau, work by politicians led to a change in marketing of alcohol:

… the biggest beer sold here is Budweiser, which comes from a US brewery in Guam. For their marketing they started labeling their cans ‘Bud Nation Palau’, ‘Bud Nation Guam’, etc. The Association of Pacific Island Legislators wrote to Budweiser requesting that they stop because we (the countries) had not given them the authority to use our name to promote their product, a product that has negative consequences for our young people. They stopped it. The politics and political support can be very important.

3.2

The Evolution of ISA for Health across the Region

ISA has taken place in the region for many years through the establishment of health promotion foundations, boards or councils. The environmental health program has been a strong driving force in the region for ISA, for example, the Healthy Islands' vision and approach which informed much policy and program development in the Pacific Islands since the mid‐1990s (WHO Regional Office for the Western Pacific ). There has been a substantial increase in the number of countries developing NCD‐specific policies since the early 2000s, most likely due to the World Health Assembly (WHA) endorsement of a global strategy on NCDs (Rani et al. ). A similar case can be made for the ‘helmet law’ from Viet Nam. While the law came into effect at the end of 2007, the multisectoral National Transport Safety Committee that leads this work was established and has been active since 1997 and related legislation was developed prior to 2007 (Passmore et al. ). It is clear that the 2011 UN high level global summit provided an important convening point for Pacific Island countries within the region, leading to an increase and/or acceleration of activity from about 2010 onwards.

3.3

Building Blocks for the Implementation of HiAP or ISA

The following sections are organised according to a number of issues that are important to understand when considering whether ISA on the social determinants of health, and health equity, and specifically HiAP, has been taking place across the region, and what factors have been important facilitators and barriers to that action.

Framing Issues and Hooks

How health is envisioned plays a role in encouraging or inhibiting ISA or HiAP. For example, the health sector in Malaysia began intersectoral policy engagement in 1971 as part of its New Economic Policy (Abdul Khalid bin Sahan ), which focused on the eradication of poverty and the restructuring of society. The health sector specifically focused on the poor and other disadvantaged groups. In Viet Nam, the incentive for introducing the helmet law does not appear to have been primarily to tackle a ‘health’ issue. The focus of the overall decree is to improve road safety and provide traffic alleviation—both of which have positive health benefits if implemented effectively. However, other commentators in the field of injury prevention have noted that it ‘… provides a powerful way of illustrating the health impacts of intervening on the social determinants’ (Roberts & Meddings , p. 244). The vision of health in South Australia makes health more of a by‐product of mutual collaboration and working with other sectors. For example, the Aboriginal mobility, safety and wellbeing work highlights how limited mobility limits autonomy, access (to services, education, recreation, work), identity (a driver's licence is one of the major forms of personal identification in Australia) and opportunities (e.g. employment prospects) and illustrates a broad vision of health (Figure ) (Kickbusch in Government of South Australia and S. A. Health , p. 6).

Aboriginal mobility, driver's licence and wellbeing Source: Kickbusch ().

More commonly in the literature, however, the entry point for ISA across the region tends to be disease focused, for example, sexually transmitted diseases (Brewis ), HIV (Narayanan et al. ), chronic respiratory disease (Varela 2010), and malaria and dengue (van den Berg et al. ).

Shifting from a Curative Agenda to a Social Determinants Agenda

All interviewees agreed that a shift in the health sector agenda from a curative, disease focused approach to a social determinant of health focus helped engage other sectors in ISA:

A shift to a promotion agenda, to social determinants, tied in with what is a more proactive community engagement strategy, such as community health, where I think that does flourish in health systems it certainly adds a lot of opportunities to interconnect with other agencies like education.

Similarly, some of the key strategic documents for NCDs illustrate how some of the countries within the region (Malaysia, Fiji and Palau) call for whole‐of‐government, whole‐of‐society responses and emphasise that this is ‘everybody's business’ (Ministry of Health Fiji ; Non‐Communicable Diseases Section Ministry of Health Malaysia ; Kuartei , ). Highlighting sectoral co‐benefits from ISA is important. For example, soft‐drink taxes among Pacific Island countries (Thow et al. ) were justified taxes in terms of their contribution to health and the benefits for the finance and trade ministries in terms of additional revenue.

Doing ISA or HiAP

All of the interviewees highlighted that it was important not to present a HiAP approach as an entirely new way of doing things but as a way of improving and adding value to existing and previous approaches. For example, among Pacific Island countries, there is a long history of a broader inter‐disciplinary approach to tackling health issues, particularly with regard to NCDs and related risk factors. Health promotion and protection are identified as essential existing structures for the change process, with environmental health as an important bridge to other health programs and working with other sectors (WHO Regional Office for the Western Pacific ). Similarly, in Malaysia, intersectoral work occurs but this is not practised under the name of ‘HiAP’.

The Role of Different Stakeholders

Highest Level of Government 

Central government has been important in facilitating HiAP. Viet Nam's helmet law was introduced as part of a longer term process driven by the National Transport Safety Committee and chaired by the Ministry for Transport, reporting to the Prime Minister (Passmore et al. ). In Fiji and Palau, while NCD action is being led by the Minister for Health, the commitment to action and whole‐of‐government or society action is underlined by a commitment from the Prime Minister or President. The HiAP program in South Australia is driven by achieving cross‐government goals and targets in the South Australian Strategic Plan.

Ministries of Health 

At the policy level, Ministries of Health can play an influential role in supporting HiAP. A study of governance in response to NCDs among select countries in the region (Cambodia, Fiji, Malaysia, Mongolia, Philippines) examined three dimensions—institutional arrangements for stewardship and program management and implementation; policies or plans; and multisectoral coordination and partnerships. Over a 10‐year period, they found several positive trends, including a shift from specific NCD‐based programs (e.g. a program for diabetes control) to integrated NCD programs and approaches, and increasing inclusion of NCDs (and linked risk factors) in health sector plans. With regard to multisectoral collaboration on NCDs, four countries had a committee for NCDs (Cambodia, Fiji, Mongolia and Malaysia). In Cambodia and Fiji, the chair of the committee was the Minister of Health, and in Mongolia and Malaysia, the Prime Minister and Deputy Prime Minister, respectively (Rani et al. ).

Non‐Health Ministries 

As demonstrated, the case from Viet Nam suggests that action on injury prevention is an important convening point for ISA, particularly when framed in terms of transport and/or road safety policy, and the formulation and overall coordination for the helmet law in Viet Nam was led by the Ministry for Transport (Passmore et al. ).

Communities and Non‐Governmental Organisations 

The literature positions communities, and by extension community linked organisations as being a necessary component of ISA (Brewis ; McDonald et al. ; Chien & Norman ; Englberger et al. ; Roberts & Kuridrani ; Atkinson et al. ). In Malaysia, women's NGOs helped to put violence against women onto the policy agenda (Colombini et al. ). In Vanuatu, incorporating the community in the design of food or nutrition interventions including education (Dancause et al. ) and involving community representatives in the Island Food Community NGO has facilitated the development of new products from high‐nutrient local foods (Englberger et al. ). Most policy‐makers said that civil society organisations were very important in moving the agenda forward. The importance of collaborations between government, NGOs, particularly faith‐based NGOs and the community was raised.

Private Sector 

Linking to the private sector is also seen as an important HiAP or ISA strategy (McDonald et al. ; Ebomoyi & Srinivasan ). For example, the Asia Injury Prevention Foundation (AIPF) played a significant role in the public education and awareness raising aspects of the helmet law, particularly in schools (Asian Injury Prevention Foundation ).

System Support at Multiple Levels

Most interviewees thought that both formal structures (e.g. statutory inter‐departmental review groups, parliamentary committees, legal instruments) and informal processes were key drivers for effective intersectoral engagement. They highlighted the need for an approach that supports the agendas of collaborating actors, and to ensure that each actor gains from the engagement. Also, while the structures in government can be helpful, they can also become a hindrance if not set up to accommodate the current needs.

I think you need a mandate to act. I think cross‐sectoral committees can work. For more sustained, ongoing engagement, my experience is that formal processes and structures are nice, but don't often get acted on. There is plenty of legislation that doesn't get implemented, millions of policies. I think you can't rely on that (formal structures) alone—that won't work. It is about the approach, and it's about being useful. If other agencies find the approach useful, if it supports their agenda, and they get something out of the engagement that wouldn't have received if they weren't engaging, that is probably the most powerful thing.

Financial Support

The evidence suggests that funding, both actual and in‐kind support, is needed to facilitate intersectoral work by, for example, supporting committee meetings and governance processes.

I guess a pragmatic answer to that one is that direct financial support for anything makes it more effective. In terms of schools, with limited budgets, and always wanting to be able to explore the possibility of accessing other budgets, the school Principals would probably say yes. But I'd have to say, that going on what I just said before, if this is an exercise in co‐construction and intellectualising our work at a conceptual level, you don't need direct financial support for that; it's about people sitting down and thinking flexibly about what they can do better and what they can do with others.

People—Initiative, Interests and Leadership

People play an important role in supporting ISA, which is intertwined with structural and organisational factors. As noted, leadership is essential to influence new ways of working (Abdul Khalid bin Sahan ; Glensor ; Benzian et al. ; Colombini et al. ). Individual leaders can play coordinating roles, thereby encouraging sustainability of ISA partnerships and initiatives (Lin et al. ). Training people in positions of responsibility and authority to advocate for changes in policies is identified as successful (Allotey et al. ). Politically connected champion's progressing issues are also identified (Narayanan et al. ). Individual initiative in the absence of structural supports is also seen as critical (Colombini et al. ).

3.4

Key Drivers of an Equity Lens

Does ‘Health Equity’ Encourage ISA

The differing use and interpretation of terminology across sectors poses a challenge if trying to use ‘health equity’ as a hook to encourage ISA and a HiAP approach. In Fiji, however, using the term ‘health equity’ instead of specific diseases has been useful in getting other partner's support:

I find the term useful. I think they are more comfortable with it. Up until now, we've felt that the other partners tend to look at the Ministry of Health as a disease type of entity, so when we discuss it in terms of health equity, they [other partners] seem to buy into it more.

In Practice: Equity as an Explicit Target or Outcome of HiAP or ISA

Equity was reported in the literature as an explicit target for a number of activities: primary health care (Glensor ); disaster preparedness (Ferrier & Spickett ); women's health (Yadav ; Yip & Anderson ; Allotey et al. ; Yip et al. ); education and school health (Curtin & Nelson ; Benzian et al. ); intellectual disability (Lin et al. ); and food and nutrition (Wahlqvist & Kuo ). However, the influence of ISA on equity in outcomes did not appear to have been evaluated. Equity was most commonly referred to in the context of ‘vulnerable’ groups, defined in terms of age groups or life stages (e.g. babies, unborn generation, children, mothers to be or older people).

Equity was also not mentioned in the telephone interviews as an explicit target. Similarly, in the detailed case studies developed for this project, we found that equity was rarely framed explicitly or as an expected outcome of the work—with the exception of the Aboriginal mobility, safety and wellbeing in South Australia. While equity does not appear to be an explicit target of the helmet law in Viet Nam, there is an implicit focus on equity through the distribution of 50,000 free helmets to low income families in advance of implementation of the law (Passmore et al. ).

3.5

How to Sustain ISA for Health

Structural Barriers and Facilitators

Siloed structures and funding for specific sector activities were reported as the main barrier to ISA (McNair et al. ; Roberts & Kuridrani ; Benzian et al. ). The ability to see and coordinate activity beyond these silos to a holistic view of issues is required from policy to service delivery (Chien & Norman ; Glensor ; Englberger et al. ; Colombini et al. ). Facilitators were mainly identified in relation to developing and sustaining partnerships (Wahlqvist & Kuo ). Having a clear strategy (Glensor ) and identifying enabling principles facilitated these partnerships (Benzian et al. ). The infrastructure and sustainable financing mechanisms available through health promotion foundations are also key facilitators. In the interviews, policy‐makers noted the importance of promoting creative ways of thinking and working, linking individual agency with structural changes within institutions and organisations.

All government agencies forever run up against the limitations of individuals and groups to better understand how they could shape their organisations in different ways. All institutionalised inertia is something that is a worldwide issue. And I put it down to, not the apportioning of blame, but simply our intellectual capacity to think differently about our work. I think part of promoting HiAP is partly about promoting the ability and methodology of looking at what others do, and also promoting the ability to have a dialogue with your community about what their needs are. That's as much a dispositional thing as anything else.

Knowledge and Skills for HiAP or ISA

A number of the people interviewed believed that there is a lack of knowledge surrounding HiAP, why it is necessary and its potential outcomes. Demonstrating the importance of HiAP and the social determinants of health to other sectors will be an important step in facilitating HiAP initiatives.

In the context, the two groups of disease have different causes. The first one is easy, responsibility is easy for Ministry of health—the cause is easy. Vs. NCD: cause is social determinants: [there] needs to be a mindshift to understand this change. We are not curing diabetes with medicine, but it's the eating, and the drinking, and the physical inactivity and tobacco; these are very important if we need to control NCD in our country. The country is more reactive vs. proactive, but we need to be proactive: we need to talk about social determinants in NCDs and not organisms.

The NCD epidemic seems to serve as the main focal entry point to the social determinants of health, partly because it validated not looking at the issue from the disease perspective and brought in the different sectors work as a determinant. However, the lack of a specific framework or mandate for HiAP policies was considered a significant barrier to the long‐term sustainability of such initiatives.

Given the complex, intersectoral and often interdisciplinary nature of HIAP or ISA work, it was interesting that the review of evidence in the region and the interviews with policy‐makers did not identify any regular dedicated programs tha aim to build the capacity of policy‐makers and public health professionals for this work. Notably, in the Pacific Island countries, as part of a meeting with academics about Academia's response to the NCD crisis within the region held in September 2011, the following issue about capacity for policy action is noted: ‘… much of control of NCDs lies outside health. It was therefore important not to have courses in issues such as nutrition only, but also in areas such as policy development, advocacy etc.’ (Snowdon , p. 5).

The interviewees identified that a crucial capability enabling the success of HiAP implementation is the ability to embed sustainable long‐term change. It is necessary to clearly define the end goal, to use an evidence‐based approach and to allocate resources such that the change is sustainable. From a leadership perspective, it is necessary to establish a dialogue with the people who will bring about the change, to maintain a sense of ownership, and with the local community, so that that they remain open to the initiative and recognise the practical benefits. Capacity building, followed by resource development, was recognised as being beneficial before the broad implementation of HiAP.

Good health diplomacy will facilitate collaboration and is crucial to improve the ability to determine, and articulate, the pathway between policy and health and wellbeing. Population health research is valued for its ability to quickly pull together evidence and to effectively plan programs. These skills are necessary to drive HiAP, but should be utilised in a way where there is a lot of listening.

I think for the health personnel, it's really important to have good health diplomacy, to understand when to push and when to sit back in terms of when to encourage collaboration.

4.

Discussion

This article has identified a range of HiAP, and more broadly ISA for health activity within countries across the Western Pacific Region. By focusing on the experience from policy‐makers in several jurisdictions, the existing literature from the region, and case studies, we have unpacked various dimensions of successful and unsuccessful practice. These findings support the literature from elsewhere that HiAP and/or ISA are necessarily multifaceted policy approaches that include progression of health and health‐related issues as important policy ideas across government and sectors, institutional mandates and organisational support for those ideas, and a skilled workforce to implement them and progress action (Baum et al. ; Carey et al. ; Harris et al. ).

While HiAP is not recognised uniformly as a useful framing for action, action to this effect is occurring across the region and encompasses institutional support in the form of a range of issue‐focussed activities (with NCDs and an increasing interest in social determinants of health as entry points), and skilled collaboration in working across sectors and disciplines within, often, a politically driven environment.

There are a number of important lessons from the regional experience. First, it is important not to talk about HiAP as though it is new. If key decision‐makers are required to start using a whole new terminology for existing processes that engage across government departments and sectors, it will distract and potentially detract from what is achieved so far. Therefore, how HiAP is introduced as being the same as or different from ISA affects how policy‐makers will take the issue forward both as an agenda item and a strategy. This leads to the second lesson, which is the need for clarification about what is meant by HiAP—how and why is it different from what policy‐makers and practitioners are doing now, including (i) if they are already pursuing ISA as part of a wider health improvement approach, and they are being asked to change course using HiAP, it is important to know how much is required that is new or needs to be ‘tweaked’, and (ii) to enable systematic documentation of related activities and facilitate knowledge exchange that will equip policy‐makers working in the health sector to work effectively with other sectors to improve the health equity impacts of their policies over time.

A third lesson from the review is that the consideration of health equity in HiAP needs more explicit attention: this is not a new observation. However, there is still an assumption that everyone will benefit equally from action with and by other sectors, thus reducing health inequities between different population groups, and that action does not need to focus on the distribution of determinants such as housing, education and how they affect inequities. For example, the location of public green spaces in urban environments, are they in the most disadvantaged areas or in the most advantaged? It tends to be assumed that everyone will benefit equally when action on these factors occurs.

There is also room for improvement in clarifying the intent of action on equity—to improve the health of vulnerable groups, close the gap or reduce differences between all groups. There is relatively little assessment of impact in relation to equity and specified goals. This is changing and is reflected in a more systematic documentation of examples such as application of this framework for reviewing and presenting these HiAP examples. However, more often than not, the example of ISA is implicitly considered to be benevolent and hence positive in impact and therefore acceptable in terms of health equity. Yet, this is not known and usually not tested.

Finally, the framework used to inform our data collection proved a useful heuristic. The regional exercise provided an important opportunity to test the database and in application identified some areas that still require clarification, particularly on defining health equity, health equity targets and measurement. However, ongoing and systematic collection of examples using this type of framework—even where information is not fully available and/or the action does not have a focus on health equity—is important to advancing the theory that HiAP is important to improving population health and health equity by amending public policy‐making across sectors in order to achieve the most favourable impacts.

There are a number of limitations concerning the evidence base used here. Most articles retrieved through the literature search described potential topic areas for ISA and, especially those mentioning multiple countries, principles for ISA rather than the practice of ISA. Another area of significant ISA activity not captured in the primary literature review was the use of health impact assessments. This occurs across the region but has been particularly prominent in Australia (Harris & Spickett ) and New Zealand (Haigh et al. ). Further discussion is also needed on the intersection between primary health care and ISA.

5.

Conclusion

This article provides some useful ‘pearls’ from the Western Pacific Region about HIAP and ISA. The findings highlight the importance of being clear about what is meant when we talk about ‘new’ approaches. It goes without saying that policy‐makers and practitioners of HiAP and ISA work in diverse country and policy contexts. This means they may be undertaking collaborative action with other sectors for population health improvement and/or improved health equity but calling it something different. There is much to be learnt from these examples, which may or may not be labelled ‘Health in All Policies’.

Irrespective of the label, in the past decade, there has been a positive shift to recognising the need to assess the health equity impact of health and non‐health sector initiatives. This has moved from a generic statement of positive intent to reduce health inequities to more specific actions. However, it remains a challenge to find documented examples that demonstrate impact in relation to equity. With time and support, it is expected that this will improve. This improvement however will not improve without more systematic documentation of examples of ISA as part of a HiAP approach, including whether equity was an explicit goal, the intended change in equity and the results from any evaluation in terms of health equity impact.