What we can learn from Québec’s Health in All Policies approach
While some other Canadian jurisdictions have adopted elements of a HiAP approach, Québec is the first provincial jurisdiction to substantively adopt and implement it.
Lindsay McLaren and Temitayo Famuyide
A recent Global Network for Health in All Policies (GNHIAP) webinar focused on Québec’s adoption of a Heath in All Policies (HiAP) approach, which takes an inter-sectoral approach to policy with the intent to promote population health and equity.
This is significant because the Québec initiative potentially represents the embodiment of longstanding scholarship on the social determinants of health and health equity. A crux of that scholarship is that health is importantly shaped by the quality of circumstances—including natural environments—in which we are born, grow, live, work, and age and their public policy antecedents.
From that perspective, improving population health and redressing health inequities cannot be limited to the health sector but, rather, demands a coordinated ‘whole of government’ or ‘whole of society’ approach. While some other Canadian jurisdictions have adopted elements of a HiAP approach, Québec is the first provincial jurisdiction to substantively adopt and implement it.
As scholars of public health who are situated in the field’s deep and longstanding tensions between applied policy/practice and critical scholarship around upstream determinants of population well-being and health equity, we attended this webinar with great interest.
The webinar provided an excellent opportunity to learn about Québec’s HiAP implementation from the perspective of two experts. First, Dr. Horacio Arruda, Assistant Deputy Minister and former Director of Public Health for Québec’s Ministère de la Santé et des Services Sociaux (MSSS), shared first-hand experience with Québec’s Politique gouvernementale de prevention en santé (government policy for health prevention).
Adopted by the Québec government in 2016, the politique is a “whole-of-government approach aimed at improving population health and reducing inequalities.”
One notable element is that it requires a health impact assessment to be conducted on policies within and outside of the health sector. This is mandated by legislation.
Moreover, the politique rests on a foundation of collaboration, in which the health sector plays a role of convenor rather than leader (“Health leadership is important but not sufficient”). This is important with respect to the well-known pitfalls of health imperialism, where the health sector presumptively and arrogantly takes leadership and assumes that health is everyone’s main priority.
Second, Denis Maron spoke to the municipal perspective, from his significant experience as former mayor of Massueville in the Montérégie region of Québec and president of the Réseau Québécois de villes et villages en santé. He provided examples of collaboration between municipalities and provincial government departments (e.g., Prendre soin de notre monde) aimed at mobilizing municipal actors on issues related to the social determinants of health.
Mr. Maron’s presentation strongly conveyed that municipalities, at least in the Québec context, seem to be an untapped and willing ally for action on the social determinants of health from their important local stance.
Overall, the session was informative and energizing in several respects. There was strong recognition—which remains absent in most mainstream health discourse—that one “can’t do health without the determinants of health” and that prevention and reduction of social inequalities require active involvement of “the whole of society”.
The efforts to ‘de-silo’, by building shared vision and goals, are significant.
Finally, the fact that the politique initiative has persisted across multiple governments is notable, and it offers some optimism with respect to the constant challenge of short-term thinking in government.
However, considering the webinar’s focus on “promoting health and equity” (italics added), the session also left us with some questions, which we believe should be at the forefront of HiAP and intersectoral efforts more generally.
Where and how equity figures into these initiatives was not entirely clear to us.
The politique, for example, has a broad range of objectives and targets. While some are “upstream” oriented, such as those focusing on affordable housing and sustainable mobility; others are focused on single health issues like smoking, fruit and vegetable consumption, and positive parenting practices.
Considering the longstanding problem in public health of lifestyle drift, where health policy-makers begin with a recognition of social, economic, and political determinants of health, only to drift back into policies aimed at modifying individual behaviors, it is reasonable to ask whether inclusion of these behaviour-focused targets in fact presents a distraction to upstream, equity-oriented policy.
Moreover, most of the politique’s targets are articulated in terms of “% of the population who …”. This can serve to individualize the issue and to draw attention away from the systems and structures that cause them.
Take for example: “Increase by 20% the proportion of 12 to 17 year olds who are active during leisure and travel time.” Can we be optimistic that this target will prompt meaningful efforts to tackle the dominance of the private vehicle and the powerful vested interests in maintaining that status quo? These “upstream” dynamics of power and politics are known to obstruct substantive shifts towards public and active forms of transportation across Canadian cities.
Health inequities are fundamentally caused by inequities of power and resources.
If equity is a stated goal of HiAP, then a depoliticized set of indicators and targets is not innocuous.
The nature of the targets and indicators may reflect the compromise that seems inherent to intersectoral work in the pursuit of “win-win” arrangements. While this seems reasonable on the surface, one must also ask, “win-win” but according to whom, and at what cost to key goals such as equity?
Said differently, what is the benefit of working hard to get everyone on the same page, if it is a heavily diluted page? One need look no further than the recent U.S. House Speaker election to recognize the potentially significant perils of compromise.
Although HiAP is explicitly concerned with equity, we do not recall hearing the word “equity” in the webinar. We certainly did not hear “capitalism”, “colonialism”, “exploitation”, or “white supremacy”.
In our contemporary neoliberal capitalist economic system, it seems almost absurd to suggest that we should hear those terms in a government-focused webinar. But perhaps that is the whole problem.
We have become accustomed to a version of government (including in public health) characterized by incrementalism and oriented to risk management rather than bold visions in which equity—and those most impacted—is centred, and in which the systems and structures that work against equity are actively dismantled.
Shifting this dynamic will require the struggle that can only come from broad, civil society organization and mobilization.
It will also require massive efforts within public health itself to wrestle with, and work to overcome, the insidious influence of medicalization and individualism, and the power and politics within our field that sustain them, for which one need look no further than the COVID-19 pandemic response.
In summary, there is much to learn from Québec’s adoption of the HiAP approach. It provides important experience and inspiration around significant challenges presented by silos between and among both departments and levels of government, and short-term thinking.
Meaningful advancement towards equity, however, seems very limited. If we are serious about that goal, then considerably more and better engagement, critical reflection, and effort by all of us is required.
Lindsay McLaren is a Professor, and Temitayo Famuyide is a PhD student, in the Department of Community Health Sciences at the University of Calgary.