The role of policy instruments in implementing Health in All Policies approach - A comparative study

Abstract Background Previous studies have recognized that implementation of Health in All policies (HiAP) is complicated. Most studies have focused on technical aspects of implementation, while the dimension of power has received less attention. This paper applies a governance approach which departs from the notion that power does not only reside in the sites of high level decision-making, such as in the Ministry of Health or in the Prime Ministeŕs Office, but in the everyday work of civil servants and those mundane practices and tools that are used to guide the actors and organizations in implementing national policies. Methods The data consists of policy documents (2019-24) and expert interviews from Finland, Germany and Italy. Theory-driven content analysis is applied to identify different policy instruments. Study design is a multi-site comparison as we focus empirically on 3 cases. Results The instruments are categorized in 5 groups: legislative and regulative; economic and fiscal; agreement- and incentive-based; information- and communication-based; standards and good practices. Results indicate that the use of different instruments within countries is often overlapping, which adds versatility in guiding HiAP- policies, but also complexity in governance. Results also indicate that the more interlinked and overlapping they are (in any particular issue), the stronger their influence grows. Conclusions Building a systematic approach to HiAP implementation with close interlinkages between various policy instruments is recommended. This signifies that in order to strengthen implementation it is not enough to regulate by a law, but you should add an indicator to monitor it and fiscal instrument to incentivize its use. Key messages • The role of policy instruments is an understudied area and must be considered when analyzing the implementation of HiAP approach. • Including power into the analysis is essential as it has key relevance to success or failure of HiAP.