Communities in the United States face multiple public health crises, from the increasing threat of climate-related disasters to the legacy of racial oppression against Black, Indigenous, and People of Color to the chronic disease epidemic. These crises are known as “wicked” problems due to the multiple drivers at the institutional and structural levels that require intentional, multifaceted solutions.1 Research on the social determinants of health has shown that an individualʼs health is largely determined by the social, political, and environments where he or she lives, learns, works, plays, and prays. These are shaped by government agencies, businesses, community organizations, and other local institutions with decision-making or political power. Therefore, these actors and organizations shaping the environment need to collectively and comprehensively address the social, political, and ecological barriers keeping communities from achieving optimal health outcomes. One approach to systematically incorporate health considerations into decision-making processes is to implement a Health in All Policies (HiAP) framework. The National Association of County and City Health Officials (NACCHO) defines HiAP as a change in the system that determines how decisions are made and implemented by local, state, and federal governments to ensure that policy decisions have neutral or beneficial impacts on health determinants.2 Originating in the European Union in 1999, HiAP is a relatively new public health framework that was formally introduced in the United States in 2010 by then California Governor Arnold Schwarzenegger when he signed into law an executive order creating the Health in All Policies Taskforce.3–5 Local health departments (LHDs) are uniquely positioned to lead or support HiAP implementation in their communities because they possess the legal authority and mission to protect and promote the public's health. LHDs, however, are not capable of implementing HiAP alone. Cross-sector representation from governmental agencies, community stakeholders, and other local organizations in HiAP efforts ensures that policies and programs consider the intended and unintended impacts of decisions on community health outcomes.
In the decade since the California executive order, HiAP practice has grown tremendously at the local level in the United States, although the strategies and tactics used to implement HiAP vary greatly. In 2013, a seminal review completed by Gase et al6 distilled 7 common strategies for HiAP implementation, including developing and structuring cross-sector relationships; incorporating health into decision making; enhancing workforce capacity; coordinating funding and investments; integrating research, evaluation, and data systems; synchronizing communications; and implementing accountability structures. From this review, NACCHO developed a widely used factsheet in 2014 that illustrates how different LHDs are implementing each HiAP strategy.2 Building on the creation of the factsheet, NACCHO has supported LHDs to develop and adopt HiAP resolutions, build an evidence base for HiAP practice, and most recently captured stories from health departments using HiAP partnerships to respond to and mitigate the COVID-19 crisis.
Over the last 10 years, HiAP has been adopted by jurisdictions across the United States through a variety of mechanisms. In 2014, NACCHO supported the development and adoption of a HiAP resolution in Richmond, Virginia, and in 2015 participated in an implementation workshop with local government representatives.7 After seeing the value of the HiAP resolution in Richmond, NACCHO began identifying communities with HiAP resolutions or executive orders and making them available on our HiAP Web page as we become aware of them.8 Although these initiatives have similar goals, they vary quite a bit in terms of directives and scope. For example, the city of Pinellas Park, Florida, directly calls for the hiring of a health planner to implement HiAP9:
SECTION TWO: That the Mayor and City Council of the City of Pinellas Park support the decision to hire a Health Planner to implement HealthImpact Assessments to ensure projects are evaluated based on their health implications in addition to traditional metrics.
Other jurisdictions have established cross-sector task forces instead of one position. For example, the city of Appleton, Wisconsin, created the Interdepartmental Health in All Policies Team and then required certain actions such as selecting health and health equity indicators for each department10:
(c) Establish the Interdepartmental Health in All Policies Team. The Interdepartmental Team will be comprised of representatives from departments within the City.
(1) Selecting health and health equity indicators for each department to track as a way of prioritizing goals and measuring progress aligned with existing City guiding documents including, but not limited to the Comprehensive Plan and Green Tier Charter.
In terms of scope, HiAP resolutions and initiatives have been established for cities, counties, or entire states.11,12 Each year more jurisdictions are employing HiAP in their work and evolving their current HiAP processes to continue to focus on the determinants of health of their communities. While LHDs do not need to have a HiAP resolution, it can be useful for building momentum and providing accountability to the public. Since 2010, more than 5 states and 20 local jurisdictions have adopted a formal HiAP policy or initiative and countless public health practitioners utilize informal HiAP strategies to protect the health of their communities.8 NACCHO intends to continue to provide support to LHDs developing resolutions and updating the online map linking practitioners to examples from across the country.
Although a handful of state and local health departments have shown the benefits and success of HiAP through evaluation, the practice has lacked substantial evidence to truly understand the impact on communities. To address this gap, NACCHO, in partnership with the Florida Department of Health in Pinellas County and the Multnomah County Health Department, Oregon, developed a tool for LHDs to evaluate their HiAP initiatives. By utilizing the 7 strategies and 4 HiAP implementation phases,13 the evaluation tool provides LHDs, local government staff, and other community-based organizations with an example framework and metrics to help build an evidence base for HiAP practice. The tool intends to be used as a guidance tool with examples rather than a strict protocol since there is such great variance in HiAP policies, initiatives, and goals as noted earlier. NACCHO's next steps will be to fund LHDs to use the evaluation tool and to start identifying data collection tools (eg, interview guides, surveys) that can be used to measure HiAP metrics and thus further support health departments to evaluate their progress.
Using HiAP Partnerships During the COVID-19 Response
Most recently in spring 2020, NACCHO worked to capture and elevate stories from LHDs across the country that were able to utilize partnerships developed through HiAP initiatives to inform their COVID-19 response and recovery work. NACCHO held a listening session with local and state public health practitioners in April 2020 where health departments shared how they have utilized the partnerships cultivated to implement HiAP.14 This includes adjusting guidance and process for eviction notices; opening parks and other open space safely for both park staff and the public; working with homeless shelters to create guidance around screening and restructuring their congregant housing spaces; reopening or relocating farmers markets with appropriate measures in partnership with food advocates; and utilizing a HiAP fellow to conduct contact tracing. Throughout the sharing session, it was clear that practitioners are being creative and making the best out of a difficult situation. They are finding new collaborative ways to provide support and care to the communities they serve.
HiAP practitioners responding to COVID-19 have also started looking toward the future to plan how their communities may be impacted in the long term by the pandemic. For example, one community is starting to ask itself how to continue to use spaces such as sidewalks and streets more effectively. The community had shut down streets to allow appropriate social distancing while being outdoors. Another community is thinking through how it can be thoughtful and authentic with its community engagement postresponse. Getting to our new normal and restarting work put on hold due to COVID-19 will require collaboration, not only to mitigate the ongoing threat of community spread but also to adapt to the expected economic and social implications of COVID-19. Currently, NACCHO is working with several partner organizations to develop an article examining how HiAP initiatives at the state and local levels have helped communities become more resilient and better able to adapt to the changing circumstances brought on by COVID-19.
The Next 10 Years of HiAP
In the early days of HiAP practice, many public health professionals were cautious that HiAP is more of a vision statement than an achievable, implementable practice. Since the 2010 resolution, NACCHO has worked with many partners, funders, and communities to highlight examples, create actionable resources, and more broadly support the implementation of HiAP in local jurisdictions to better inform the practice in moving from concept to application. As we move into the next decade of HiAP practice in the United States, NACCHO will continue to support LHDs to implement HiAP, illustrate the value of investing resources in HiAP, and better highlight and incorporate racial inequity as an explicit focus in the development of future HiAP tools, resources, and presentations.
1. Kickbusch I, Buckett K, eds. Implementing Health in All Policies: Adelaide 2010. Adelaide, South Australia: Health in All Polices Unit, SA Department of Health; 2010:3. https://www.who.int/sdhconference/resources/implementinghiapadel-sahealth-100622.pdf
. Accessed September 11, 2020.
2. National Association of County and City Health Officials. Local health department strategies for implementing Health in All Policies. https://www.naccho.org/uploads/downloadable-resources/Programs/Community-Health/factsheet_hiap_dec2014-1.pdf
. Published December 2014. Accessed September 11, 2020.
3. Council of the European Union. Council Resolution of 18 November on Ensuring Health Protection in All Community Policies and Activities. Brussels, Belgium: Council of the European Union; 1999.
4. National Association of County and City Health Officials. Health in All Policies: experiences from local health departments. https://www.naccho.org/uploads/downloadable-resources/NACCHO-HiAP-Report_Experiences-from-Local-Health-Departments-Feb-2017.pdf
. Published 2017. Accessed September 11, 2020.
5. Cal Exec Order S-04-10 (2010).
6. Gase LN, Pennotti R, Smith KD. “Health in All Policies”: taking stock of emerging practices to incorporate health in decision making in the United States. J Public Health Manag Pract. 2013;19(6):529–540.
7. Kerner B. NACCHO hosts first Health in All Policies (HiAP) workshop in Richmond, VA. https://www.naccho.org/blog/articles/naccho-hosts-first-health-in-all-policies-hiap-workshop-in-richmond-va
. Published January 20, 2016. Accessed September 17, 2020.
8. National Association of County and City Health Officials. Health in All Policies. https://www.naccho.org/programs/community-health/healthy-community-design/health-in-all-policies
. Published 2020. Accessed September 11, 2020.
9. Pinellas Park, Fla, Resolution 19-11 (2019).
10. Appleton, Wis, City Ordinance 15-18 (2018).
11. Wash Senate Bill 6197 (2006).
12. Tacoma-Pierce County, Wash, Resolution 2016-4495 (2016).
13. Association for State and Territorial Health Officials. HiAP implementation stages. https://www.astho.org/HiAP/Framework
. Published 2018. Accessed September 11, 2020.
14. National Association of County and City Health Officials. HiAP/COVID-19 listening session. https://www.naccho.org/programs/community-health/healthy-community-design/health-in-all-policies?searchType=standard&lhd-state=WA#card-filter
. Published April 2020. Accessed September 11, 2020.