Health in all policies: where to from here?

One of the key goals for health promotion has been ‘to move health high on the political agenda’. This was stated clearly in the Adelaide recommendations of 1988 (WHO, 1988) and has been a key goal of health advocacy ever since. Today health has moved up the political agenda to an extent one could not have envisaged even 10 years ago—for example, it was a defining factor in the US elections 2008 and of the first year of the Obama presidency. Why is this? Health has become vital to overall government performance at the national level and a key factor in voting behaviours in democracies and of government legitimacy in autocratic states. The reasons are manifold for example: the control of health care costs is now considered as a key tenant for broader economic stability and growth of societies as well as a component of competitiveness of national economies; the overall costs to society of certain health conditions are increasingly discussed and include concerns about the effect of population ageing on both the economy and productivity. Health is also ever more present in the international arena, not only in the discussions at the World Health Assembly, but also at the United Nations, at the G8 and the G20, and at other international organizations such as the World Trade Organization, the OECD and the World Bank. At the global level health intersects with security as well as trade and intellectual property issues, health has become a core factor of development strategies such as the Millennium Development Goals. It is linked to foreign policy and the geo-political and economic interests of countries. The growth of the health care industry and the increasing mobility of patients and health professionals constitute a new dimension in the global arena. Finally health intersects with many other agendas such as climate change and food security. Health is increasingly visible in the public and political debate in many ways for example: cuts in health care provision, rising insurance premiums, vaccination in relation to global pandemics, the regulation of products such as tobacco, alcohol or fast food, the price of medicines or the issue of major health inequalities. All these relate to larger agendas such as the freedom of markets, the responsibility of individuals, the protection of vulnerable groups and the extent of state intervention. This makes any health issue inherently political and in many cases transports it into the realm of ideology as is evident in the conflict between health interests and market forces. In summary one could say that health is in the process of moving from being a vertical and sectoral issue to one that relates significantly to larger societal goals and in consequence gets mired in the conflicts that emerge in the definition of such goals.