How and why buy-in for health in all policies was facilitated in Ecuador: a realist case study of Plan Nacional para el Buen Vivir.

BACKGROUND: In 2008, Ecuador introduced Plan Nacional para el Buen Vivir (PNBV; National Plan for Good Living), which was widely recognized as a promising example of Health in All Policies (HiAP) due to the integration of policy sectors on health and health equity objectives. PBNV was implemented through three successive plans (2009-2013, 2013-2017, 2017-2021). In a time of widening global health inequities, there is growing interest in understanding how politics and governance shape HiAP implementation. The objective of this study was to test specific hypotheses about how, why, to what extent, and under what circumstances HiAP was implemented in Ecuador. METHODS: An explanatory case study approach (HiAP Analysis using Realist Methods on International Case Studies-HARMONICS) was used to understand the processes that hindered or facilitated HiAP implementation. Realist methods and systems theory were employed to test hypotheses through analysis of empirical and grey literature, and 19 key informant interviews. This case study focused on processes related to buy-in for a HiAP approach by diverse policy sectors, particularly in relation to the strong mandate and transformative governance approach that were introduced by then-President Rafael Correa's administration to support PNBV. RESULTS: The mandate and governance approach of the HiAP approach achieved buy-in for implementation across diverse sectors. Support for the hypotheses was found through direct evidence about buy-in for HiAP implementation by policy sectors; and indirect evidence about allocation of governmental resources for HiAP implementation. Key mechanisms identified included: influence of political elites; challenges in dealing with political opposition and 'siloed' ways of thinking; and the role of strategies and resources in motivating buy-in. CONCLUSION: In Ecuador, political elites were a catalyst for mechanisms that impacted buy-in and government funding for HiAP implementation. They raised awareness among policy sectors initially opposed to PNBV about the rationale for changing governance practices, and they provided financial resources to support efforts related to PNBV. Specific mechanisms help explain these phenomena further. Future studies should examine ways that PNBV may have been an impediment to health equity for some marginalized groups while strengthening HiAP implementation.

How and why do win-win strategies work in engaging policy-makers to implement Health in All Policies? A multiple-case study of six state- and national-level governments.

BACKGROUND: Much of the research about Health in All Policies (HiAP) implementation is descriptive, and there have been calls for more evaluative evidence to explain how and why successes and failures have occurred. In this cross-case study of six state- and national-level governments (California, Ecuador, Finland, Norway, Scotland and Thailand), we tested hypotheses about win-win strategies for engaging policy-makers in HiAP implementation drawing on components identified in our previous systems framework. METHODS: We used two sources of data - key informant interviews and peer-reviewed and grey literature. Using a protocol, we created context-mechanism-outcome pattern configurations to articulate mechanisms that explain how win-win strategies work and fail in different contexts. We then applied our evidence for all cases to the systems framework. We assessed the quality of evidence within and across cases in terms of triangulation of sources and strength of evidence. We also strengthened hypothesis testing using replication logic. RESULTS: We found robust evidence for two mechanisms about how and why win-win strategies build partnerships for HiAP implementation - the use of shared language and the value of multiple outcomes. Within our cases, the triangulation was strong, both hypotheses were supported by literal and contrast replications, and there was no support against them. For the third mechanism studied, using the public-health arguments win-win strategy, we only found evidence from Finland. Based on our systems framework, we expected that the most important system components to using win-win strategies are sectoral objectives, and we found empirical support for this prediction. CONCLUSIONS: We conclude that two mechanisms about how and why win-win strategies build partnerships for HiAP implementation - the use of shared language and the value of multiple outcomes - were found as relevant to the six settings. Both of these mechanisms trigger a process of developing synergies and releasing potentialities among different government sectors and these interactions between sectors often work through sectoral objectives. These mechanisms should be considered when designing future HiAP initiatives and their implementation to enhance the emergence of non-health sector policy-makers' engagement.

Implementation of Health 2015 public health program in Finland: a welfare state in transition.

Our study sought to examine the implementation of Health 2015 [a public health programme prepared following the principles of Health in All Policies (HiAP)] between 2001 and 2015 in the context of welfare state restructuring. We used data from the realist multiple explanatory case study by HARMONICS, which focused on political factors (processes) that lead to the (un)successful implementation of programmes following the principles of HiAP. We analyzed data-key informant interviews, grey and scholarly literature-from our Finnish case to examine how Health 2015 implementation has been affected by the changing role of the state. We find that the dismantling of formal funding allocation decreased the capacity of national authorities to exert control over municipalities' health promotion work, diluting the financial arrangements regarding municipal obligations. As a result, most municipalities failed to contribute to Health 2015, resulting in losses for health promotion activities. Our results also point to joining the EU. Whereas the procedures for preparing Finland's unanimous positions on EU matters were useful in harmonizing ideologies on various policy issues between different ministries, joining the EU also increased commercial interests and the strength of the lobby system, leading to the prioritization of economic objectives over public health objectives. Finally, our informants also highlighted the changing relationship between the state and the market, manifested in market deregulation and increasing influence of pro-growth arguments during the implementation of Health 2015.

Resisting austerity measures to social policies: multiple explanatory case studies.

Since Margaret Thatcher reached power in the United Kingdom, European governments have increasingly turned to neoliberal forms of policy-making, focusing, especially after the 2008 Great Recession on 'austerity policies' rather than investing in social protection policies. We applied a multiple explanatory case studies methodology to examine how and why challenges and resistance to these austerity measures are successful or not in four settings for three different social policy issues: using a gender lens in state budgeting in Andalusia (Spain), maintaining unemployment benefits in Italy and cuts to fuel poverty reduction programs in Northern Ireland and England. In particular, we intended to learn about whether resistance strategies are shared across disparate cases or whether there are unique activities that lead to successful resistance to austerity policies. As our approach drew from realist philosophy of science, we started with initial theories concerning collective action, political ideology and political power of affected populations. Our findings suggest that there are similarities between the cases we studied despite differences in political and policy contexts. We found that joint action between advocacy groups was effective in resisting cuts to social spending. Evidence also indicates that the social construction of target populations is important in resisting changes to social programmes. This was observed in both England and Northern Ireland where pensioners held significant political clout.

The implementation of Health in All Policies initiatives: a systems framework for government action.

BACKGROUND: There has been a renewed interest in broadening the research agenda in health promotion to include action on the structural determinants of health, including a focus on the implementation of Health in All Policies (HiAP). Governments that use HiAP face the challenge of instituting governance structures and processes to facilitate policy coordination in an evidence-informed manner. Due to the complexity of government institutions and the policy process, systems theory has been proposed as a tool for evaluating the implementation of HiAP. METHODS: Our multiple case study research programme (HiAP Analysis using Realist Methods On International Case Studies - HARMONICS) has relied on systems theory and realist methods to make sense of how and why the practices of policy-makers (including politicians and civil servants) from specific institutional environments (policy sectors) has either facilitated or hindered the implementation of HiAP. Herein, we present a systems framework for the implementation of HiAP based on our experience and empirical findings in studying this process. RESULTS: We describe a system of 14 components within three subsystems of government. Subsystems include the executive (heads of state and their appointed political elites), intersectoral (the milieu of policy-makers and experts working with governance structures related to HiAP) and intrasectoral (policy-makers within policy sectors). Here, HiAP implementation is a process involving interactions between subsystems and their components that leads to the emergence of implementation outcomes, as well as effects on the system components themselves. We also describe the influence of extra-governmental systems, including (but not limited to) the academic sector, third sector, private sector and intergovernmental sector. Finally, we present a case study that applies this framework to understand the implementation of HiAP - the Health 2015 Strategy - in Finland, from 2001 onward. CONCLUSIONS: This framework is useful for helping to explain how, why and under what circumstances HiAP has been successfully and unsuccessfully implemented in a sustainable manner. It serves as a tool for researchers to study this process, and for policy-makers and other public health actors to manage this process.

A glossary of terms for understanding political aspects in the implementation of Health in All Policies (HiAP).

Health in All Policies (HiAP) is a strategy that seeks to integrate health considerations into the development, implementation and evaluation of policies across various non-health sectors of the government. Over the past 15 years, there has been an increase in the uptake of HiAP by local, regional and national governments. Despite the growing popularity of this approach, most existing literature on HiAP implementation remains descriptive rather than explanatory in its orientation. Moreover, prior research has focused on the more technical aspects of the implementation process. Thus, studies that aim to 'build capacity to promote, implement and evaluate HiAP' abound. Conversely, there is little emphasis on the political aspects of HiAP implementation. Neglecting the role of politics in shaping the use of HiAP is problematic, since health and the strategies by which it is promoted are partially political.This glossary addresses the politics gap in the existing literature by drawing on theoretical concepts from political, policy, and public health sciences to articulate a framework for studying how political mechanisms influence HiAP implementation. To this end, the glossary forms part of an on-going multiple explanatory case study of HiAP implementation, HARMONICS (HiAP Analysis using Realist Methods on International Case Studies, harmonics-hiap.ca), and is meant to expand on a previously published glossary addressing the topic of HiAP implementation more broadly. Collectively, these glossaries offer a conceptual toolkit for understanding how politics explains implementation outcomes of HiAP.

Using Win-Win Strategies to Implement Health in All Policies: A Cross-Case Analysis.

BACKGROUND: In spite of increasing research into intersections of public policy and health, little evidence shows how policy processes impact the implementation of Health in All Policies (HiAP) initiatives. Our research sought to understand how and why strategies for engaging partners from diverse policy sectors in the implementation of HiAP succeed or fail in order to uncover the underlying social mechanisms contributing to sustainable implementation of HiAP. METHODS: In this explanatory multiple case study, we analyzed grey and peer-review literature and key informant interviews to identify mechanisms leading to implementation successes and failures in relation to different strategies for engagement across three case studies (Sweden, Quebec and South Australia), after accounting for the role of different contextual conditions. FINDINGS: Our results yielded no support for the use of awareness-raising or directive strategies as standalone approaches for engaging partners to implement HiAP. However, we found strong evidence that mechanisms related to "win-win" strategies facilitated implementation by increasing perceived acceptability (or buy-in) and feasibility of HiAP implementation across sectors. Win-win strategies were facilitated by mechanisms related to several activities, including: the development of a shared language to facilitate communication between actors from different sectors; integrating health into other policy agendas (eg., sustainability) and use of dual outcomes to appeal to the interests of diverse policy sectors; use of scientific evidence to demonstrate the effectiveness of HiAP; and using health impact assessment to make policy coordination for public health outcomes more feasible and to give credibility to policies being developed by diverse policy sectors. CONCLUSION: Our findings enrich theoretical understanding in an under-unexplored area of intersectoral action. They also provide policy makers with examples of HiAP across wealthy welfare regimes, and improve understanding of successful HiAP implementation practices, including the win-win approach.

Glossary for the implementation of Health in All Policies (HiAP).

Health in All Policies (HiAP) is becoming increasingly popular as a governmental strategy to improve population health by coordinating action across health and non-health sectors. A variety of intersectoral initiatives may be used in HiAP that frame health determinants as the bridge between policies and health outcomes. The purpose of this glossary is to present concepts and terms useful in understanding the implementation of HiAP as a cross-sectoral policy. The concepts presented here were applied and elaborated over the course of case studies of HiAP in multiple jurisdictions, which used key informant interviews and the systematic review of literature to study the implementation of specific HiAP initiatives.