# In Centralized Health Systems, Much Is Left Out When Analyses of Local HiAP Strategies Are Limited to Public Administration

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Comment on “A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland”

Eric Breton* ID, Yann Le Bodo ID

**Abstract**

We argue that the lessons drawn by Guglielmin and colleagues, from the Health in All Policies (HiAP) approach in the municipality of Kuopio, are of limited use to centralised health systems. There is a need for research more attuned to the circumstances of local governments that have little power over the provision of health programmes; yet can address a range of determinants of population health. In these cases, adopting a state-centric perspective may fail to capture the role of other actors such as non-governmental organizations (NGOs) and local branches of state agencies. Evidence from France shows that centralised health systems can foster HiAP locally through political commitment and dedicated coordination staff whose role is to mobilise and support NGOs, inhabitants, and other local branches of regional and central governments. We highlight, as three important challenges, the issue of legitimacy, funding and positioning of the HiAP instrument in the local government structure.

**Keywords:** HiAP, System Theory, Governance, Community Health, Health Inequalities, France

**Copyright:** © 2023 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Citation:** Breton E, Le Bodo Y. In centralized health systems, much is left out when analyses of local HiAP strategies are limited to public administration: Comment on “A realist explanatory case study investigating how common goals, leadership, and committed staff facilitate Health in All Policies implementation in the municipality of Kuopio, Finland.” *Int J Health Policy Manag.* 2023;12:7646. doi:10.34172/ijhpm.2022.7646

**Article History:**

Received: 24 August 2022

Accepted: 21 November 2022

ePublished: 1 January 2023

**\*Correspondence to:**

Eric Breton

Email: eric.breton@ehesp.fr

**Introduction**

In their paper, Guglielmin et al¹ provide a convincing analysis of the implementation of the Health in All Policies (HiAP) governance in the municipality of Kuopio (Finland). Much credit ought to be given to their contribution as there are too few theory-based analyses in this field that offer transferable knowledge and applicable lessons in other places. In this commentary, we argue that, albeit valuable, the Kuopio case study can do little to advance practice and policymaking in countries where health and other government responsibilities are centralised at the national level. We conclude by calling for a broader research agenda on HiAP.

**What Can the Implementation of HiAP Bring to Population Health?**

An HiAP perspective on improving population health is certainly essential for public health practitioners and policymakers who believe in the powerful role that local, regional and national governments can play in improving living conditions and thus in reducing health inequities.²

But the value of the HiAP approach may, at times, go well

beyond incremental improvements in the way governments operate. Its full potential is best observed in tackling complex issues that current governance configurations and processes are unable to address effectively. Social inequalities (and their reproduction across generations), mental health issues, gender-based violence and adaptation to global warming are just a few examples of complex problems that not only require the mobilization of a diversity of sectors and resources within societies, but also require innovative solutions.

While Guglielmin et al¹ rightly remind us that part of the impetus for HiAP is rooted in a holistic perspective on the social determinants of health – and that health is indeed much more than the absence of disease – it is also worth noting that the outcome of a HiAP instrument cannot be fully understood through a traditional causal perspective. The analyst of a local policy-making process that involves a wide range of partners and who examines its various artefacts (minutes of meetings, reports, memorandum of understanding, etc) may be surprised by the innovative nature of the solutions that result from such processes. These solutions often lie at the intersection of different sectors such as housing and mental
health, urban planning and physical activity and climate
change and nutrition. From a system theory perspective, when
new connections are established within a system of actors,
they enable the mobilization of new agents and resources
that can generate emergent properties (ie, new behaviours,
objects, and environments that cannot be deduced from the
singular properties of the people or means involved). In the
complexity theory literature, a classic illustration of emergent
properties is the meeting of oxygen and hydrogen to form a
molecule (water) whose properties cannot be subsumed to
the individual added properties of the two types of atoms. The
community health literature is peppered with examples of
such phenomena.3,4 In short, HiAP embodies causal processes
that lead to transformations that cannot be fully captured
through a linear Cartesian and clockwork lens on the nature
of things and phenomena. In the human and natural worlds,
generative causality has also to be accounted for.5

Let us now look at what we can learn (or not) from the
Finnish case.

The Limits of the Finnish Case for Drawing Lessons for Other
Health Systems

One issue left unaddressed is that of power or, more
specifically, the locus of political power in decision-making.⁶
We do not believe that Finland's presence at the forefront
of the adoption/implementation of a HiAP approach is
coincidental. Guglielmin et al¹ remind us of the country's
achievements in implementing a democratic ethos, with
much of the public services provided by local governments
whose elected officials and civil servants enjoy great social
proximity. Many people are amazed by the stories of elected
representatives cycling to parliamentary sessions or doing
their shopping like any normal person. In Finland, there is
clearly a sense of closeness between the political elite and
their constituents that is difficult to achieve in the context of
centralised governance.

This being said, Guglielmin et al have adopted an
exclusively public service perspective on health policies,
when a whole array of actors can also play their part in
improving population health by drawing on the resources of
the municipality. Again, for more centralised health systems
at national level, municipalities often have little power over
matters such as health and education, for example. France
is one of the countries where mayors of local municipalities
have little say on the provision of healthcare services and
prevention programmes. In health matters, their mandate is
officially limited to hygiene and sanitation. Yet, as we will see
below, this does not mean that the implementation of a HiAP
instrument is not feasible.⁷

This public service perspective on HiAP also leads the authors
to turn a blind eye to the influence that non-state actors (non-
governmental organizations [NGOs], local businesses...) play
in policy development and implementation. Yet, when vested
interests hinder efforts towards a cross-sectoral municipal
approach and favour the status quo, these actors can prove
valuable in driving change. Beyond their intrinsic usefulness
in providing tailor-made services close to the population,
they can therefore be crucial in giving life to a HiAP approach

over a territory.

A key issue in HiAP research boils down to a simple question: how do you identify a HiAP scheme when looking at a set of state agencies? To their credit, Guglielmin et al provide a partial answer by framing a “successful” HiAP implementation as “policy implementation outcomes including acceptability and feasibility of implementation across parties involved, and sustainability of the HiAP implementation process.” However, they overlook an essential property of HiAP schemes, which is that they generate actions, policies and ultimately changes that are simply beyond the reach of any individual actor. In other words, they combine resources and capacities previously managed individually.

The Importance of Investigating Other Forms of HiAP
Instrument

France offers an interesting case of intersectoral mobilisation
at the local level.⁸,⁹ Acknowledging the lack of coordination
between the actions implemented by NGOs funded by
Regional Health Agencies and different central state
agencies and ministries, the 2009 Health Act¹⁰ opened up the
possibility for Regional Health Agencies to sign agreements
(ie, contracts) with local authorities setting a number of
actions to improve population health. Local health contracts
are not legally binding, but entail a population health need
assessment that can potentially foster a new dynamic between
local stakeholders. Our national survey of the local health
contract,⁸,⁹ as well as additional analyses based on qualitative
data collected in the regions of Brittany and Pays de la Loire,
have highlighted some of their most interesting features.

The first observation we can draw from our survey is the
significant diversity in the topics covered by the contracts.
From our sample (53 contracts out of 165 signed between
January 2015 and March 2018), we can say that no two local
health contracts are alike, an aspect which points to their
capacity to adapt to local contexts. Their range of thematic
actions goes from environmental/occupational health to
substance use, nutrition, violence, housing, access to primary
care, etc.

A second feature of local health contracts is the critical role
played by their coordinators. They are the hub of the HiAP
apparatus. The coordinators know all the NGOs and local
state agencies involved in the contract, and it is to them that
these organisations turn to when they encounter problems,
need support in obtaining funding or partners, or even just
need a meeting room. We also found coordinators linking
up NGOs with technical experts from different municipal
services. They also facilitate the flow of information and
ideas and are often able to quickly identify emerging issues in
population groups where action is needed.

This brings us to the third feature of the local health
contracts: their ability to generate intersectoral collaboration.
In analysing the actions listed in the contracts, we found many
examples of solutions that required partners to work across
silos. In one example, partners from the nutrition, land use
and community sectors joined forces to deliver a school-based
intervention to improve young people's knowledge of healthy
diets, while simultaneously creating space for an organic
waste management site. In our view, and as mentioned above, such examples are clear evidence that HiAP governance is being successfully implemented.

Yet, as much as local health contracts in France can
compensate, to a certain extent, for the lack of linkages between
a centralised health system and the local fabric, these contracts
face many challenges that can impair their capacity to stand
as HiAP instruments. As we have observed, the coordinators
largely embody what local health contracts are about. The
functions of coordinators and the conditions under which
they are performed naturally bring us to the sociological work
of Jeannot and Goodchild on local partnerships.¹¹ Based on
Jeannot's earlier work,¹² these authors identify what they call
fuzzy jobs¹¹ which share three main characteristics: (1) an
ambiguous position in the organization; (2) a very general job
description; and (3) a more precarious employment contract
than that of the average public sector worker.

These three characteristics resonate well with the multiple
accounts we collected from coordinators who were recruited
solely for the duration of the local health contract. These
positions typically attract young professionals, a situation
that explains the high staff turnover regularly reported by
Regional Health Agencies. An important condition for the
success of local health contracts is the involvement of elected
officials. The mayor or his/her deputy in charge of health or
social matters legitimises the approach and thus facilitates
the mobilisation of local partners. They also determine the
coordinator's position in the local government's organisational
set-up, making him/her more or less visible and integrated
into the structure. What is at stake here, in the positioning
of the coordinator, is not only the institutional legitimacy
that it entails, but also whether the coordinators can see
themselves as fully integrated in the state apparatus or just
another element that can be easily discarded. Although we
lack sufficient quantitative data to support our claim, our
interviews showed that the lack of effective integration of
coordinators weakens the capacity of local health contracts to
generate and maintain changes.

In regard to their job description, when asked about their
work, local health contract coordinators typically struggled to
describe their role. What is even more remarkable is that they
often undervalued their capacity to mobilise and connect
with professionals from different sectors. This may suggest
that the skills associated with intersectoral/HiAP approaches
have yet to achieve recognition and enter mainstream training
programmes.

Finally, another element that weakens the HiAP instrument
is the fact that, apart from the coordinator's salary, the health
contracts have no secured funding (an issue highlighted by
Guglielmin et al¹). Coordinators therefore invest a significant
amount of their time in helping local partners to apply
for grants to fund the actions listed in the contract. The
experience of the current pandemic seems to have further
demonstrated the importance of having HiAP instruments
such as local health contracts, supported by substantial and
stable funding. The funding provides some flexibility, making
it easier for the local network of stakeholders to initiate and
implement solutions to previously unforeseen challenges.

Conclusion

The study of exemplary cases such as Kuopio is undeniably
essential for generating new insights. Undoubtedly,
Guglielmin and colleagues' finding on the fact that a common
language among partners does not seem to be a requirement
for collaboration goes against what is commonly taken for
granted.⁸ However, there are valuable lessons to be drawn from
cases nested within more centralised systems of governance,
where most of the levers of power to alter resource allocation
and change practice and policy are not locally based. In these
cases, we may need to adopt a less state-centric approach to
gain a clearer perspective on the alternatives in implementing
HiAP. And however elusive the essence of a HiAP instrument
may be, it is basically an evolving network (or a network
of networks) bringing together a range of state agencies,
resources and professionals working within the fabric of the
broader society.

Research and efforts towards the implementation of HiAP
strategies are essential to improving population health. As
public health researchers and practitioners, we are frequently
reminded of how weak public health institutions are in
improving the very living conditions that contribute to health
inequities.² The power we do have is the one we can mobilise
through partnerships with other, much more powerful
sectors. In other words, ours is borrowed power.

Acknowledgements

Authors want to thank the following members of the
CLoterreS research consortium for their contribution in the
conduct of the project: Yann Bourgueil, Dieinaba Diallo,
Herve Hudebine, Cyrille Harpet, Françoise Jabot, and Candan
Kendir.

Ethical issues

The CLoterreS project was reviewed by the institutional review Board of the French Institute of Medical Research and Health (INSERM) (opinion number: 18-495).

Competing interests

Authors declare that they have no competing interests.

Authors’ contributions

EB wrote the first and second version of the manuscript. YLB commented and brought significant improvements to the 2 versions.

Funding

This work was supported by the French Public Health Research Institute (IReSP: BRETON-AAP16-PREV-16).

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