Health in all Policies (HiAP): A Realist Multiple Explanatory Case Study Examining the Implementation of HiAP

Health in All Policies (HiAP) is a health promotion strategy that aims to improve population health and equity through a whole-of-government approach to the development and implementation of public policy. This dissertation tests the hypotheses about factors that shape implementation of health in all policies in multiple jurisdictions. The study: (1) through a narrative review, reviewed public health perspectives on HiAP, focusing on the role of politics in implementation, (2) using a single explanatory case study, advanced theory about buy-in for HiAP in California, and (3) through a multiple explanatory case study, advanced theory about the influence of non-state actors in HiAP implementation in a number of jurisdictions, namely, California, Norway, Ecuador, Thailand, and Scotland. Data for the narrative review were obtained from the peer-review literature and data for the explanatory case studies relied on primary data collected during 2012 to 2015 and secondary data extracted from the HARMONICS (HiAP Analysis using Realist Methods On International Case Studies) study at the St. Michael’s Hospital Centre for Urban Health Solutions. The narrative review provided broad perspectives on political considerations in the HiAP literature, while the realist explanatory case study methodology advanced theories of the mechanisms involved in the implementation of HiAP in multiple jurisdictions. These methodologies were complemented by the systems framework which serves as a heuristic tool to aid policy makers and HiAP researchers better understand how government sectors implement HiAP initiatives, and how non-governmental actors shape implementation. Primary findings are multifaceted. First, the narrative review revealed a paucity of political considerations in the public health literature on HiAP implementation. Second the findings revealed strong evidence on the factors that contributed to buy-in in California. We found buy in for HiAP occurs when: 1) there is a history of prior experience, 2) governments employ knowledge translation, 3) governments employ sectoral language, 4) governments use dual outcomes, 5) governments use expert advisors and, 6) governments employ consensus building. Third, the findings of the cross-case analysis of non-state actors influence on HiAP implementation found weak support for the influence of supranational institutions, medium support for private sector, low support for civil society.Ph.D