9.G. Workshop: Health in all Policies: key driver for better health still awaiting of greater governing stewardship

Abstract   Healthy public policies are those that take accountability of all possible health impacts, acknowledging the causal pathways resulting from the modification of upstream health determinants (e.g. transport strategies, etc.), and related risk factors downstream (e.g. air pollutants). The strategy of Health in All Policies (HiAP), promoted by the World Health Organization (WHO) and adopted by the European Union (EU) in 2006, reinforced the need to reduce inequalities and improve health and wellbeing as essential pillars for a sustainable economic development. Central to HiAP is the notion that health is not only the responsibility of the health sector, but also a shared responsibility with many other sectors. In this context, Health impact Assessment (HIA) was proposed as the combination of methods to support HiAP implementation by providing scientific evidence on the positive and negative effects that any new proposal may have on health and health equity. The COVID-19 pandemic, and the climate change threat, are two of the main challenges that emphasise the need of integrated responses across many sectors to mitigate not only effects on health and inequalities, but also in the economy. However, HiAP and HIA implementation remains almost at a conceptual level, with a few remarkable exceptions in Europe. One of the most relevant reported barriers contributing to this uneven HiAP implementation is the lack of political stewardship and commitment. The difficulties in applying the guiding principles of HiAP (and consequently of HIA) at local, regional, or national governance level are in many cases linked to a conflict between the right to work and mobilization of the economy, with the right to health and reduction of inequities. This is where the role and drive of public health actors comes across, as HiAP requires public health professionals to build partnerships and engage meaningfully with the sectors affecting the social determinants of health and health equity, external to the health sector. A good proxy example to HiAP implementation, facilitating local and regional initiatives with communities, is the WHO initiative of Healthy Cities. The present panel discussion intends to analyse, from different perspectives, why HiAP has not gained a meaningful place within governing contexts, the current and future status of the intersectoral approach, and the advocacy role of public health in this context. The session is scheduled with a first overview presentation followed by a debate framed around the following aspects: – Different perceptions regarding the concrete implementation of HiAP at all political levels. – Perceived barriers or trade-offs for a broader implementation of HiAP. – Role of public health actors in the implementation of HiAP at a strategic, policy level, and how it could gain a more prominent role. – Level of understanding and awareness of the utility of HIA for HiAP implementation by public health actors. Key messages • HiAP, a recognised approach requiring all sectors to address decisions’ health and equity implications for reaching better global health, has not yet been implemented with an overarching vision. • Public Health actors can disentangle political and technical aspects, seeking for synergisms, and clarifying to non-health sectors the complexity and interrelatedness of social health determinants.


Background:
Last year Europe registered >365 000 excess deaths, most from preventable causes. In order to timely track deaths, the Portuguese Directorate-General of Health developed a deep neural network that codifies ICD-10 causes of death (AUTOCOD) by analyzing free text in a death certificate (DC). While the performance of AUTOCOD has been demonstrated, it was not clear if it was sustained during excess mortality periods, when text quality could be lower due to the increased pressure on health services.

Methods:
We performed a sensitivity analysis comparing the ICD-10 classifications of 330 098 Portuguese DC by AUTOCOD and by human-coders, from 2016 to 2019. Excess mortality was defined using the EuroMOMO methodology and a subanalysis in periods of extreme excess (+4 and +6 SD). We compared the periods without excess mortality with the periods of excess and extreme mortality by chapter. The same analysis was performed for ICD-10 blocks, for the three most common chapters (neoplasms; diseases circulatory and respiratory system). The confusion matrixes allowed us to calculate AUTOCOD's performance metrics, like sensitivity. Results: AUTOCOD showed high sensitivity (0.75) in 10 chapters, with values above 0.90 for the three most common ones. The weighted-average of sensitivity showed no difference between periods without excess mortality and periods of excess mortality, a difference of 0.01 for periods of extreme mortality (+4 SD) and a difference of 0.04 for periods of extreme mortality (+6 SD). For the block classification, performance was similar.

Conclusions:
Even in periods of excess and extreme mortality, AUTOCOD accurately predicts the classification of the cause of death. Meaning that it is not affected by a potential loss in textquality due to pressure in health services. This allows for the use of AUTOCOD for real time mortality surveillance and it highlights the importance of Artificial Intelligence as an advisory tool for Public Health policies in emergencies.

Key messages:
Artificial Intelligence algorithms like AUTOCOD can predict the ICD-10 cause of death with very high sensitivity, during periods with and without excess mortality. Artificial Intelligence algorithms like AUTOCOD can be used for real-time cause specific mortality surveillance, providing valuable information for policy making during periods of excess mortality. Healthy public policies are those that take accountability of all possible health impacts, acknowledging the causal pathways resulting from the modification of upstream health determinants (e.g. transport strategies, etc.), and related risk factors downstream (e.g. air pollutants). The strategy of Health in All Policies (HiAP), promoted by the World Health Organization (WHO) and adopted by the European Union (EU) in 2006, reinforced the need to reduce inequalities and improve health and wellbeing as essential pillars for a sustainable economic development. Central to HiAP is the notion that health is not only the responsibility of the health sector, but also a shared responsibility with many other sectors. In this context, Health impact Assessment (HIA) was proposed as the combination of methods to support HiAP implementation by providing scientific evidence on the positive and negative effects that any new proposal may have on health and health equity. The COVID-19 pandemic, and the climate change threat, are two of the main challenges that emphasise the need of integrated responses across many sectors to mitigate not only effects on health and inequalities, but also in the economy. However, HiAP and HIA implementation remains almost at a conceptual level, with a few remarkable exceptions in Europe. One of the most relevant reported barriers contributing to this uneven HiAP implementation is the lack of political stewardship and commitment. The difficulties in applying the guiding principles of HiAP (and consequently of HIA) at local, regional, or national governance level are in many cases linked to a conflict between the right to work and mobilization of the economy, with the right to health and reduction of inequities. This is where the role and drive of public health actors comes across, as HiAP requires public health professionals to build partnerships and engage meaningfully with the sectors affecting the social determinants of health and health equity, external to the health sector. A good proxy example to HiAP implementation, facilitating local and regional initiatives with communities, is the WHO initiative of Healthy Cities. The present panel discussion intends to analyse, from different perspectives, why HiAP has not gained a meaningful place within governing contexts, the current and future status of the intersectoral approach, and the advocacy role of public health in this context. The session is scheduled with a first overview presentation followed by a debate framed around the following aspects: -Different perceptions regarding the concrete implementation of HiAP at all political levels.
-Perceived barriers or trade-offs for a broader implementation of HiAP.
-Role of public health actors in the implementation of HiAP at a strategic, policy level, and how it could gain a more prominent role.
-Level of understanding and awareness of the utility of HIA for HiAP implementation by public health actors. This presentation sets what HiAP is and is not, and its evolution since it was conceived. It also addresses how HiAP can be mobilised in practice via the use of tools such as HIA and the key role that enabling structures and contexts -both politically strategic and locally operational-to ensure that health, wellbeing and equity is promoted in the European region. It discusses the enabling context of Wales, with the Future Generations (Wales) Act 2015, which provides political leverage for the implementation of HiAP in practical terms, enabling addressing health considerations intersectorially by non-health policies and projects. This Act along with supporting documents, guidance and legislation implicitly incorporates the principles of HiAP so the rest of non-health sector understand (and also have the statutory obligation) to address the health considerations of policies and plans. It does this by requiring all public bodies in Wales to strive to maximise 7 Well-being Goals -which include 'A healthier Wales', 'A more equal Wales' -and requires that they do so by working with other agencies in order to prevent negative impacts and promote participation, long-term thinking and integration to ensure that inequalities are minimised. These are key public health principles from which to have conversations.
Wales also provides a good example with its advocacy and policy in respect to Economies of Wellbeing -a critical challenge for HIAP is that HiAP is, by its nature, political, and may challenge some policy proposals. Although the focus is on identifying 'win:wins' and co-benefits, sometimes there is a conflict between health and other outcomes. There may be a need to balance health gains against economic growth or other policy aims. The following debate intends to discuss the challenges and enablers to achieve that aim, and how public health can make its voice heard. COVID-19 pandemic response was an opportunity to advocate for HiAP as everyone developed opinions on how policies could affect the different dimensions, including health and economy. Health planning, from the local to the international level, is the main setting where we still need to advocate for the inclusion of all political sectors and actors in order to ensure an effective HiAP implementation. From a more technical perspective, there is still a lot to do when it comes to implementing and improving economic evaluations, including on data on costs, valuing benefits or using cost-effectiveness approaches.