Health in All Policies: Unfunded mandate?

By Joshua Waimberg, JD

Beginning in the early 2000s, there was a push in the public health world for jurisdictions and localities in the United States to adopt a Health in All Policies (HiAP) approach similar to recent initiatives in Europe. At its core, HiAP is a collaborative approach to improve the public’s health by incorporating health into decision-making across sectors and policy areas.

According to the Public Health Institute, HiAP is centered around five core elements: promoting health and equity, supporting intersectoral collaboration, creating co-benefits for multiple partners, engaging stakeholders, and creating structural or process change. It can be adopted at all levels of government, and jurisdictions that adopt HiAP approaches do so to ensure that all decision-makers and stakeholders work together to improve the health of their communities.

The Policy Surveillance Program, with support from the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts, has just published that detail state-level HiAP bills and laws that were proposed or passed between the start of 2012 and the end of 2016.

Between 2012 and 2016, 19 HiAP laws were enacted or amended in nine jurisdictions, while 28 HiAP bills were introduced across 13 jurisdictions.

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One of our most interesting findings centered on the role of funding for HiAP. While 13 of the 19 enacted or amended HiAP laws required advisement on funding collaborative HiAP work, we identified that only two of the 19, both in Minnesota, specifically authorized agency use of funding for HiAP work. None of the HiAP laws established dedicated funding for HiAP work.

The situation was similar for bills proposed during this same time period: 12 of the 29 HiAP bills required recommendations on the funding of HiAP work, but only one California HiAP bill established dedicated funding for HiAP work. Only one other bill, also from California, authorized agency use of funding for HiAP work.

The challenge of funding HiAP initiatives is a crucial issue. A 2015 study of international HiAP initiatives in three countries found none had “financing mechanisms to directly fund sectors to participate in HiAP or carry out HIA.” According to the study, “[f]unding for HiAP initiatives is important, [it is] less important than a high-level commitment to intersectoral collaboration,” it also determined that “an absolute lack of financial resources is a barrier to HiAP implementation.”

Authors Pinto et al. conclude: “allocating resources and making funding decisions regarding HiAP are inherently political acts that reflect tensions within government sectors.” As our data show, funding for the majority of the collected state-level HiAP initiatives must rely on similar political acts within their jurisdictions.

The lack of dedicated or authorized agency funding for HiAP in these bills and laws, and  the reliance on generalized “advisement” on HiAP funding, is a critical issue for future HiAP initiatives.

Access the maps on Health in All Policies and health impact assessments at LawAtlas.org.

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