California's strategic growth council (SGC) recognized the need for a new policy paradigm to address difficult health-related policy problems that involve several sectors, have many interdependencies, are difficult to fully define, lack a clear solution and are not the responsibility of a single organization. They recognized HiAP as such a new policy paradigm. An executive order of the governor Arnold Schwarzenegger established the health in all policies task force in February 2010, under the auspices of the SGC, to be a cabinet-level body to enhance collaboration between state agencies.
The policy development goal was to identify priority actions and strategies for state agencies to improve community health and to thereby also advance other goals of the SGC specifically related to six other policy areas: air and water quality, affordable housing, infrastructure systems, natural resources and agricultural land, sustainable community planning, and climate change.
Another aspirational goal the task force established was that decision-makers would be informed of the health consequences of various policy options during the policy development process. This is the key operating principle of HiAP.
The first part of the HiAP task force's work has been to establish recommendations, while identifying the multiple links between policy areas, strategic growth goals, equity goals and health. The second part of the HiAP task force's work will be to develop action plans and implementation strategies.
From April-November 2010, nineteen California agencies, departments and offices came together for workshops, meetings, and to receive comment from a diverse range of stakeholders. The outcome was a set of recommendations on feasible strategies and actions.
The 19 agencies involved were: air resources board; business, transportation and housing agency; department of community service and development; department of education; department of finance; department of food and agriculture; department of forestry and fire protection; department of housing and community development; department of parks and recreation; department of social services; department of transportation; environmental protection agency; governor's office of gang and youth violence policy; governor's office of planning and research; health and human services agency; labor and workforce development agency; natural resources agency; office of the attorney general; and the office of traffic safety
The key benefit of bringing the health sector into contact with other sectors was to broaden the recognition within other sectors that the health of California's population was largely determined by the social, physical, economic and service environments in which people live, work, study and play. Health was recognised as a critical component of sustainable communities.
All the recommendations linked health goals, in terms of both health and health equity, with the issues and work of several other departments and agencies. The recommendations given below are necessarily brief, but the report goes into extensive detail on each of the points, identifying the relevant actors, existing mandates for action, as well as concrete proposals to address each issue.
The recommendations were split into two main areas: those related to promoting healthy communities and those relating to promoting healthy public policy.
Active transportation: improve community planning and increase the use of active transportation; implement 'complete streets'; incorporate safety considerations of roadway users into all programs, policies and community designs; incorporate trails and greenways; promote active transportation with state employees.
Housing and indoor spaces: encourage sustainable development through healthy housing through incentives and state guidance; secure permanent funding for affordable housing; smart housing siting, smoke-free environments for all workers and school children.
Parks, urban greening, and places to be active: encourage urban greening with access to green spaces; improved wildfire related air quality and safety; prevent and control invasive species; joint use of facilities in communities; reduce impact of tobacco waste.
Violence prevention: support community-level efforts for community engagement and joint action; use environmental design to reduce crime; target ten worst communities with new state agency action on prevention of violence; provide training and technical assistance to communities through the governor's office of gang and youth violence policy program. Add to the resources of the probation service through foundation, private sector and state agency partners.
Healthy food: expand availability of affordable locally grown produce; increase consumption of healthy foods and reduce consumption of unhealthy foods; create a California food policy council to aid in a sustainable and robust food system. Leverage government spending to support healthy eating and sustainable local food systems.
State guidance: incorporate health equity perspective into state guidance, surveys, and technical assistance documents; identify and publicize available state resources for use in healthy community planning.
Embedding health in decision-making: incorporate health and health equity criteria into state grant requests; incorporate a 'health lens' into all state legislative and policy proposals. Explore ways to integrate a health analysis into existing projects.
Data and research: incorporate health and health equity indicators into data collection tools; standardize elements and indicators for better sharing and accessibility; increase the use of evidence-based practices.
Cross-agency collaboration and expertise: foster deeper understanding and collaboration between state agencies.
Community engagement: improve opportunities for substantive community engagement in state agency decision-making.
Continue HiAP task force: continue the work of the task force to foster continued dialogue on the impact of decisions on health and health equity and to pursue the implementation of recommendations. Expand participation among relevant agencies.
The challenges faced were typical of collaborative efforts, that is, to secure adequate financial and staffing resources. Initially, knowledge of other policy areas was limited and several competing priorities were immediately visible. However, the task force set about building trust and sharing information between the actors. Many mutually beneficial links between policies areas were identified, while the task force worked hard to identify those areas where co-benefits could be advanced.
The task force worked closely with the California departments of public health (CDPH). Initially, the CDPH collected over 1200 recommendations from the various meetings with stakeholders; health professionals sifted through them to identify those with the most health impact potential. Due to the short time frame and the sheer number of recommendations, the analysis was informal, although it did consider health impact, the evidence base, equity impact, measurability, feasibility, and potential for fostering further cooperation between stakeholders.