We used thematic analysis to evaluate views regarding economic considerations among stakeholders interested in and participating in implementing HiAP using case studies from Sweden, Quebec, and South Australia. Informants consistently stated that economic considerations are important for promoting HiAP to non-health sectors within governments. This finding itself is not surprising. As others have noted when discussing HiAP, “Health partners must recognize the importance of non-health goals to non-health partners and develop an economic case for action” . However, there was considerable heterogeneity and lack of clarity in how economic considerations were conceptualized. Informants appeared to confuse affordability (i.e. this intervention is possible with our existing resources) with efficiency (i.e. this intervention is a good use of resources, given alternatives).
Economic evaluations of HiAP may provide information that better allows for a more complete cost assessment of different policy and program options. However, few robust economic evaluations of HiAP interventions have been completed to date and there are considerable conceptual and logistical challenges to such evaluations [25-28]. Methodological concerns include questions about the appropriate time horizon for an analysis, the challenges in measuring non-health benefits, and difficulties in comparing benefits on a common scale [9,10]. Costs and outcomes may accrue to different sectors of government, and capturing this data requires extensive cross-sectoral information systems. Existing evaluations on the impact and effectiveness of intersectoral action for health equity also lack descriptions of contextual factors, such as the roles and responsibilities of sectors and intersectoral relationships, and how these were related to observed outcomes of the interventions . The appropriate perspective for the evaluation also needs to be defined. A health system perspective, by definition, would be too narrow for HiAP. A societal perspective, that counts all costs and effects regardless of who pays or benefits, is often favored by economists but might be too broad for governmental decision makers. HiAP economic evaluations will need to develop methods that appropriately reflect a distinct “whole of government” perspective that incorporates relevant trade-offs related to costs and outcomes between sectors.
Many informants felt that demonstrating that HiAP is cost saving would provide strong evidence in favor of sustained implementation. Nevertheless, no informants provided evidence that downstream savings offset the cost of HiAP interventions; instead, such arguments seem to be based on intuitive comparisons of relatively inexpensive implementation costs to the high costs of downstream health and social consequences. Of note, preventative health services are similarly believed to be cost-saving but very few result in net negative costs . Other informants argued that HiAP is worthwhile because the societal cost of continued inaction to address important social determinants, such as poverty, is high. While such arguments might have validity, quantifying the effects of addressing such determinants is beyond the scope of most economic evaluations, which are typically used to guide resource allocation decisions. From this perspective, the most rigorous approach would compare the marginal net cost of a HiAP intervention, relative to a comparator, and the marginal net effects. A few informants framed economic considerations in such terms, using words such as “efficiency” or “cost-effectiveness”.
HiAP is sometimes promoted as a means to reduce health sector costs or as a mechanism for increasing public health funding [7,31]. However, focusing too strongly on the economic outcomes of HiAP might detract from the potential health and social impacts . Furthermore, several informants noted that views of HiAP can change according to economic conditions. Economic downturns and austerity budgets can represent real threats to the implementation of HiAP processes – both because HiAP might be seen as an expendable extra and because sectors become very protective of their own funds and give less priority to intersectoral collaboration . There was a strong sentiment amongst informants that implementing HiAP without dedicated funding left HiAP programs vulnerable to budget cuts.
Few studies have evaluated the costs of implementing HiAP . We note that our informants did not discuss the importance of estimating the cost of scaling up initiatives found to be good value for money. One informant noted that the opportunity cost of HiAP can be considerable if implementation diverts resources from other activities and no extra funding is allocated . Although integrated budgets and joint accounting have been identified as methods to promote the implementation of HiAP [12,19], our results are more equivocal. Multiple sources of funding might be advantageous to generate broader buy-in across levels of government but could be disadvantageous if underlying tensions within government are exposed and exacerbated. Other analyses of HiAP implementation have suggested that leadership, either political or bureaucratic, and fostering personal interactions across networks, is essential to engage diverse stakeholders and manage such tensions . Joint budgeting can be vulnerable to spending cuts as departments often start by reducing or eliminating contribution to intersectoral initiatives . Delegated financing to support HiAP processes are similarly quite susceptible to economic downturns, necessitating creative interventions to keep the public and policymakers supportive of intersectoral action to improve health . Having a specific budget for HiAP can also be a challenge if it reduces the motivation of non-health sector actors to take responsibility for the health impact of their policies .
Our study has some limitations. We used a definition of HiAP that focused on health inequities. We recognize that this may have limited the scope of our study and might limit the generalizability of our findings to HiAP interventions where equity is not a primary policy objective. We focused only on three jurisdictions and on implementations that occurred in a particular period. Our coding framework was structured around three categories that developed from initial readings. However, themes could have categorized in a number of different ways. We might have identified additional views regarding implementation and barriers to HiAP in other contexts, beyond the three case studies examined. Particularly important contextual factors might include country, economic conditions, and governmental jurisdictional responsibilities. We also did not explore some macroeconomic issues that might be important for considering HiAP, including tax policies, public and private health insurance systems, and social welfare policies. Finally, our key informants did not mention specific examples or specific policies where economic considerations had particularly been important as they implemented HiAP in their jurisdiction. This lack of concrete examples limits our findings to mostly abstract conceptualizations of how such considerations shape HiAP implementation. Future research on the economic considerations HiAP could explore its application to specific policies, such as those regulating the alcohol and food industry, or economic development and extractive industries.
Ultimately, decisions about which HiAP policies get funded and the amount of resources theyreceive are political decisions that reflect power relations both within and without government, as well as stakeholders’ values and ideological perspectives . As called for in the 2013 Helsinki Statement on Health in All Policies, there is a need for “conflict of interest measures that include effective safeguards to protect policies from distortion by commercial and vested interests and influence”  While we focused specifically on economic issues related to the implementation of HiAP interventions, future research should focus on the political economy of implementing HiAP policies.
Our results are useful for elaborating propositions for use in realist multiple explanatory case studies, a new method for understanding how macrosocial health equity interventions are implemented. This approach seeks to explain causal effects within each case by developing a specific understanding of phenomena in relation to the context while refining explanatory theory applicable to the collection of cases by testing main and rival propositions (similar to hypotheses). These propositions are a form of middle-range theory, which fall short of unified theory intending to “explain all observed uniformities of social behavior, social organization and social change” but that can help explain certain occurrences. Propositions are typically developed on the basis of existing theory, past experience and previous evaluations or research studies, including through the observation of semi-predictable, re-occurring patterns identified in data .
Accordingly, we suggest two propositions related to economic considerations and HiAP. We stress that these propositions are explanatory rather than normative; that is, they seek to explain how decisions are actually made rather than to propose how they should be made. First, we propose that economic considerations are currently used primarily as a method by health sectors to promote and legitimize HiAP to non-health sectors with the goal of securing resources for HiAP. More specifically, our results suggest that individuals responsible for implementing HiAP are primarily interested in arguments that are focused on seemingly common-sense findings (‘reducing poverty must save money’) rather than on formal analyses, whether simple (such as analyses of implementation costs or budget impact) or complex (such as cost-effectiveness analyses within or across sectors). This proposition diverges from an idealized version of economic evaluation where economic evaluations are used as the primary basis for resource allocation decisions. However, as discussed above, methods to conduct economic evaluations of HiAP initiatives are not well elaborated. Moreover, it is possible that economic arguments could detract from health concerns, perhaps for reasons related to this proposition. Taken together, these considerations suggest that economic evidence is valued for its functional role rather than as intrinsically reflecting the worth of HiAP or for guiding resource allocation decisions.
Our second proposition is that allocating resources and making funding decisions regarding HiAP are inherently political acts that reflect tensions within government sectors. More specifically, governments’ political agendas, the relative power of individual ministries or departments and the state of the economy each influenced whether HiAP was a priority for research allocation and how much funding a specific implementation received. Informants were considerably concerned about whether HiAP funding was secure, whether HiAP resources reflected opportunity costs, and whether HiAP implementation was threatened during times of economic austerity.
HiAP interventions are vulnerable for several reasons. First, HiAP is seen to come from the health sector, which already consumes a large amount of resources. Other sectors might be unenthusiastic about earmarking more funds for health, and evidence shows that even in the case of strong, government wide commitment to HiAP, economic and trade policy considerations can dampen systematic efforts to implement HiAP . As Second, HiAP interventions are sometimes seen as discretionary additions to established systems. Third, cross-jurisdictional funding and responsibility might make HiAP programs particularly vulnerable if they do not have a strong champion [6,39].