Roundtable co-chair Kindig brought the workshop to a close by asking each roundtable member to share their summary observations, and suggestions for how take these issues forward. Overall, roundtable members expressed optimism, and said they were encouraged by the innovative ideas and efforts to incorporate health into decision making in non-health sectors that were described over the course of the workshop. The following topics were highlighted by roundtable members as key takeaways from the presentations they heard.
A theme throughout many of the presentations was the close relationship between health and equity. Many participants made reference to Williams’ keynote address and the ongoing impact of historical social policy on health. A roundtable member reiterated a point by Collier in discussing nutrition and obesity, that “the choices we make are based upon the choices that we have.” What can be done to improve and expand the choices that people have? Another roundtable member summarized that sometimes our best intentions and efforts to improve communities might actually hasten some of the inequities. It is important to look at the work being done, she cautioned, and to be mindful of what the implications might be.
Roundtable members discussed further the concept that health is a bridge for cross-sector collaboration, and that successful collaboration requires a measured approach to advancing the health agenda. A member underscored the idea of convergent strategies even in the face of divergent missions and goals, and several members suggested the need for a list of win-wins or co-benefits and promising opportunities across the sectors to help drive collaboration.
One member reiterated the points made about how bringing health into the picture sometimes helps raise the acceptability or credibility of a non-health initiative, and that those health implications can be extra leverage to help other sectors move their policies or initiatives forward.
Several roundtable members observed that there was a lot of discussion about the public sector role in the Health in All Policies (HiAP) approach, and they suggested that further discussion is needed about the role of the private sector, as both stakeholder and partner. The important role of foundations was also mentioned, as was the engagement of faith communities.
Many roundtable members highlighted the critical role of the convener. It was noted that identifying the areas of overlap across different sectors, and understanding the motivations of different sectors for effecting changes that can impact health, is essential for moving population health forward. Several members noted the importance of a strategic messaging plan. How can the message about HiAP be framed so that it resonates with all stakeholders, and draws them together to work toward co-benefits? The convener can also play a role in gathering the scientific evidence and building the framework, including the business case, for the HiAP approach. Among the issues to be addressed is how to finance the role of the convener.
The topic of spread and scale was mentioned several times. There are examples of excellence, a roundtable member said, and yet there is inadequate effort to accelerate their implementation in communities. One member emphasized that there needs to be an intentional focus on harnessing these lessons learned and disseminating key elements to others.
Questions were raised about how best to approach these issues. Might it be best to focus on a particular topic? For example, a member asked if perhaps it might be easier to engage broadly on issues such as food,
exercise, and obesity, than on issues such as inequality or climate change (i.e., bike lanes are easier to talk about than income redistribution for getting communities and partners engaged). How might spread and scale activities be funded? It was pointed out that foundations play a key role in helping communities, but not to scale.
Workforce issues were also discussed relative to spread and scale. It was pointed out that moving HiAP from a concept to a “field of fields” will require a critical mass of people who can work across sectors. In this regard, it was suggested that the roundtable might take up a discussion about education and training opportunities and approaches (undergraduate, graduate, continuing education in the field) for spreading the messages, and sharing the skills and best practices for applying a health lens to non–health sector decision making. How can the skills, the abilities, and the resources be built or strengthened to enable people at the local level to do this work?
It was also suggested that the roundtable might undertake an inventory or develop a kind of catalog of the available tools, strategies, and resources that could help others in fostering cross-sector collaboration. It was pointed out that there is no place where people working on HiAP are convening, and a member suggested the roundtable might consider developing a virtual collaborative where people could engage each other for advice and support. A member added that people should be encouraged to publish their work in this area, so that promising practices and success stories can be shared.
Several individual participants raised concerns about a comment and example given by Ho indicating that, according to federal guidelines, a discretionary program that creates a cost savings in a mandatory program cannot use that as a justification for funding of the discretionary program. There was interest among the members learning more about this to gain a better understanding.
Several roundtable members discussed the challenges to defining metrics in the area of cross-sector collaboration. One member noted that in the face of limited resources, choices need to be made between approaches, and there is a lack of metrics or measures to compare efforts, to identify what works best, and develop “a learning system.” It was suggested that examples of measures from other sectors might inform health-related measures. Specifically, the existence of models that can explain the relationships between the various outcomes, for example, the impact of health care on health, and health on the ability of people to be well educated, and so forth. A member stressed that just because the evidence base around
many of these issues is still developing does not mean decision makers should wait to have all the evidence before taking action.
The question of whether there is now, or needs to be a social movement around HiAP was raised in the open discussions throughout the workshop, and highlighted again by members as a key issue in the closing session. There were differing opinions as to whether there was a movement under way, and if so, what kind of movement it was. A roundtable member observed that over the past decade there has been a shift in expectations at the community level of what people want and demand for their quality of life, and suggested that there are small movements at the community level throughout the country.
The point was made that the problem needs to be clearly defined, as does exactly what any movement is trying to achieve. Also, several individual participants commented that there is much focus on the physical determinants of health, when perhaps what is needed is more focus on the social, economic, and environmental policies that ultimately impact health.