Influence of political elites in the implementation of Health in All Policies: Evidence from HARMONICS

Given that the status quo for most governments is to have policy “silos” focused on a narrow agenda of issues, the introduction of Health in All Policies (HiAP) is usually innovative and challenging. Others have noted how HiAP and other intersectoral approaches to health equity in government have benefited from the presence of strong leadership, or, conversely, how leaders have minimized the importance of equity or the weakened program theory of equity interventions. However, there has been little explanation of the socio-psychological mechanisms by which political elites influence of the implementation of HiAP. In this explanatory multiple case study, the HARMONICS program analyzed key informant interviews and grey and peer-review literature to explain how and why political elites have influenced HiAP implementation in several international settings (Sweden, Quebec, South Australia, Scotland, Norway, Finland and California), after accounting for the role of different contextual conditions. Across certain types of contexts, we noted support for two key mechanisms. First, political elites are influential because of their formal authority to facilitate changes in governance, and second, their leadership motivates subordinates to participate in HiAP (or not). We discuss contextual factors that appear to condition which of these mechanisms was relevant in different settings, and why political elites did not appear to be influential some settings.