Bridging boundaries: Health promotion leadership in the context of Health‐In‐All‐Policies

“Partnership building,” “enabling change” and “mediating through partnerships” are recognised as core health promotion competencies, both nationally and globally.1, 2 Evidence suggests these are also key competencies for advancing Health-in-All-Policies (HiAP) approaches, and for advancing health equity and social determinants of health agendas in Australia.3 We argue that understanding the intersection between partnership competencies and leadership competencies is critical for promoting effective HiAP responses. Indeed, a recent scoping review indicated the national and local leadership are fundamental considerations,4 and that well-managed intersectoral partnerships and collaboration are critical to HiAP success.5 Yet, surprisingly, little is written about health promotion leadership competencies and qualities in Australia.6, 7 This editorial aims to unpack what leadership can look like within a HiAP context, and related leadership strategies. This includes the ability to traverse multiple disciplines and sectors. It also requires the ability to successfully navigate within and between research, policy and practice domains. It requires the tactful art of bridging boundaries. To provide some context, we have both worked in a range of health promotion roles for more than two decades. Combined, these have spanned practice, policy and research domains, predominantly in South Australia and the Northern Territory. Our work has spanned government, non-government and academic contexts. We have also worked across a variety of sectors, using core health promotion competencies to guide our work. While we both identify as being a part of the health promotion profession, we also recognise that our roles have frequently extended beyond this sphere, involving boundary spanning, and broader management and leadership functions. These experiences allow us to reflect on our ability to advocate, shape and refine the growth of HiAP approaches in Australia, and respective qualities associated with health promotion leadership and partnership building. We acknowledge there is a certain rhetoric that often underpins discussion about partnerships, collaboration and most recently co-design.3, 8 That is, it is both good and expected, but the elements of successful intersectoral collaboration are rarely clearly defined or articulated.5, 9, 10 We want to move beyond this rhetoric and talk about the messiness inherent within such leadership and partnership processes. JS recently had the opportunity to attend the East Arnhem Health Partnership Symposium. This was a partnership between NT Primary Health Network, NT Government, Menzies School of Health Research, Miwatj Health Aboriginal Corporation and the Improving Health Outcomes in the Tropical (HOT) North research collaboration. The importance of investing in health promotion and prevention was repeatedly emphasised by symposium delegates, as it often the case in Aboriginal and Torres Strait Islander health and well-being forums of this nature. Concerns raised about insufficient investment in health promotion to address well-documented health inequities were plentiful. It is a story we have both heard before many times. While there has been significant change in the health promotion landscape in Australia over the past 20 years—reflective of cyclical patterns of investment and disinvestment—the ability to improve health outcomes, particularly among those most vulnerable, has been marginal.11 It is a story that has made us reflect about what has worked well, what has not and why. It is a story that explains our current commitment to advancing a HiAP approach in Australia, and the significant potential to improve equitable population health outcomes domestically. ‘Health in All Policies is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. It improves accountability of policymakers for health impacts at all levels of policy-making. It includes an emphasis on the consequences of public policies on health systems, determinants of health and well-being.’ [12, p2]. Within a government context, this is sometimes referred to as a Whole-of-Government approach (albeit confined to government contexts), although we recognise there is some subtle nuancing between this term and that of HiAP (which can apply to broader non-government and civil society contexts). In short, it is one way to influence, and be influenced by, a multitude of sectors that sit outside the health sector to develop and implement actions likely to improve population health and well-being. Now that we have defined HiAP, we reflect on two fundamental leadership strategies required to support its success. As mentioned above, we collectively frame these strategies as bridging boundaries. More specifically, these strategies involve traversing disciplines and sectors; and navigating the research-policy-practice nexus. In public administration literature, the term boundary spanning is used to describe policy actors that understand and navigate both internal context of their own agency, and the differing context of external agencies.13 We acknowledge the strategies we have identified are not exclusive. There are many other strategies and competencies that are required to advance HiAP approaches in Australia, New Zealand and elsewhere across the globe that have been advocated by scholars and practitioners on various topics.14-16 Our aim is to distil and discuss the above-mentioned leadership strategies in a way that provokes healthy debate among HiAP enthusiasts. We encourage others to reflect on and discuss their views and opinions, and respective successes and failures, associated with adopting a HiAP approach. The ability to engage with the language and practices of diverse disciplines and sectors is a critical element of the HiAP approach.17 Within a government context, the way in which Treasury, Police and Urban Planning do business is often very different to the way Health or Education do business. For example, terms such as consultation and engagement have different meanings and can be enacted in different ways. The emphasis on health and happiness may clash with priorities associated with economic development—although we recognise that more recent discourses relating to the well-being economy are changing this dyadic polarisation. A focus on individuals, in contrast to populations, may also differ. The propensity towards principles of fairness and social justice may influence the way in which concepts such as health and social inequities are understood. Within a health promotion context, we are often person-centred in our approach. Other sectors may not share this same vision, and it is important we take time to understand this and why. The nature of partnership building as a core health promotion competency means that health promotion professionals should have the knowledge and skills to talk and walk across disciplines. Indeed, it is not unusual to see competent entry-level health promotion graduates quickly move into coordination and management roles within and external to the health system because of these skill sets. The ability to bridge disciplinary boundaries and traverse sector discourses is a leadership skill that we should not take for granted. It is a skill we should use intelligently to strengthen intersectoral partnerships and action to promote health equity.3, 9, 10 In addition to traversing disciplines and sectors, it is also important to bridge boundaries associated with policy, practice and research domains. Previous scholarship has referred to this boundary bridging as navigating the research-policy-practice nexus.18 To do this well, people advocating for, and implementing HiAP approaches, must understand and engage with the different, and sometimes opposing, ways in which these domains operate. For an academic, this is more than referencing the evidence that underpins a peer-reviewed article you have published or read; for a policy-actor, this is more than understanding the content or process of a Cabinet submission, and how and why Cabinet has made a decision likely to influence population health and well-being outcomes; and for a practitioner this is more than adopting the latest practice guidelines. It is about understanding all of these things—and many others—and the intersections between them, and the way this uneasy nexus is navigated. This includes understanding how different types of information and data are gathered and used, and by whom; whether priorities are underpinned by political ideology, fact or emerging evidence; whether a critical incident has spurred a change in policy or practice that has a time or cost imperative (eg COVID-19), or alternatively whether the issue being addressed has been festering unabated for years or decades and has suddenly received political attention or increased community interest (eg prevention of violence against women); and whether there is perceived potential among key stakeholders to enact or sustain positive change. It is important to understand whether policy priorities are Ministerially driven or have emerged as priorities through other means such as civil society action and leadership. It is critical to understand the legislative and regulatory basis for addressing key issues within and outside the health sector when advocating for health-related actions. Are legislative and regulatory changes required? Is there an appetite for change? Who is responsible for planning and implementing such change? This list goes on. It can be difficult to navigate this terrain. In our experience, people who do this well have usually worked across sectors throughout their career, or have respected and trusted colleagues working in “other” sectors that can explain key concepts and provide guidance about how best to navigate complex policy issues in the right way, at the right time. We are keen to learn more about these experiences, and the leadership qualities required to bridge boundaries. To continue this discussion, the Health Promotion Journal of Australia is planning a special issue entitled “Working together in the wellbeing economy: What role does HiAP play?” The special issue will challenge the status quo of current approaches used to address complexity. It will explore the role of HiAP and other multisectoral approaches in driving new social and economic agendas such as the well-being economy. We envisage the special issue will draw on the work of leading researchers and policy professionals from national and international health promotion, public health and political science communities. It will also focus on critical success factors, mechanisms and tools, workforce issues and the political and commercial settings necessary for change.