1. Health in All Policies in California Establishing Need and Setting Priorities March 31, 2015 Linda Rudolph, MD, MPH Center for Climate Change and Health 1

2. Acknolwedgements 2 https://www.apha.org/~/media/files/pdf/fact%20sheets/ healthinallpoliciesguide169pages.ashx Julia Caplan, Lianne Dillon, Karen Ben- Moshe, members of the California Health in All Policies Task Force, participants in the Task Force ad-hoc advisory group

3. Overview  Establishing the need for intersectoral action  Getting started: laying the groundwork for action  Determining priorities  Moving from priorities to action  Lessons learned 3

4. Establishing the Need  Who needs to be convinced? Who has power to establish a HiAP process/structure? Who can help make the case?  What do they care about? Specific issues?  Equity? Obesity? Violence? Health care costs? Chronic disease? Toxics? Climate change? Good governance?  Is there a window of opportunity?  Who needs to engage to make it work?  Establishing need is an iterative process

5. California Opportunities  AB 32: California Global Warming Solutions Act of 2006  SB375: Sustainable Communities and Climate Protection Act of 2006 5

6. Executive Order S-04-10 NOW, THEREFORE, I, ARNOLD SCHWARZENEGGER, Governor of the State of California, by virtue of the power vested in me by the Constitution and statutes of the State of California, do hereby order effective immediately: 1. The SGC shall establish a Health in All Policies (HiAP) Task Force to collaborate with existing SGC working groups to identify priority programs, policies, and strategies to improve the health of Californians while advancing the SGC’s goals of improving air and water quality, protecting natural resources and agricultural lands, increasing the availability of affordable housing, improving infrastructure systems, promoting public health, planning sustainable communities, and meeting the state’s climate change goals. 2. The Task Force shall be facilitated and staffed by the California Department of Public Health 6 Health in All Policies Task Force Facilitated by

7. California’s HiAP Task Force Planning Process 1200 suggestions  Multiple 1:1 meetings with each member agency throughout process  Review literature  Review existing plans, mission statements, etc.  Develop joint one-page issue briefs with members  On-going Task Force and cluster meetings  Ad-hoc stakeholder advisory group meetings  Multiple 1:1 meetings with experts & advocates  Eight community forums around state 7

8. Laying the groundwork  Why am I here?  What’s in it for me? 8

9. What is a Healthy Community? A healthy community provides the following for all residents across all stages of life: 9 Meets basic needs of all Safe, sustainable, accessible and affordable transportation options Affordable, accessible and nutritious foods and safe drinkable water Affordable, high quality, socially integrated and location-efficient housing Affordable, accessible and high quality health care Complete and livable communities including quality schools, parks and recreational facilities, child care, libraries, financial services and other daily needs Access to affordable and safe opportunities for physical activity Able to adapt to changing environments, resilient, and prepared for emergencies Opportunities for engagement with arts, music and culture Quality and sustainability of environment Clean air, soil and water, and environments free of excessive noise Tobacco- and smoke-free Green and open spaces, including healthy tree canopy and agricultural lands Minimized toxics, greenhouse gas emissions and waste Affordable and sustainable energy use Aesthetically pleasing Adequate levels of economic, social development Living wage, safe and healthy job opportunities for all, and a thriving economy Support for healthy development of children and adolescents Opportunities for high quality and accessible education Health and social equity Social relationships that are supportive and respectful Robust social and civic engagement Socially cohesive and supportive relationships, families, homes and neighborhoods Safe communities, free of crime and violence

10. Root Cause Mapping Why is Jason Sick?  Why is Jason in the hospital?  But why does he have an infection?  But why does he have a cut on his leg?  But why was he playing in a junkyard?  But why does he live in that neighborhood?  But why can't his parents afford a nicer place to live?  But why...? Citation: © Her Majesty the Queen in right of Canada, represented by the Minister of Public Works and Government Services Canada, 1999. 10

11. Outcome Contributing Factor Jason is sick Cut on leg Infection Root Causes Playing in junkyard Lack of nearby playground Fell on jagged steps Unsanitary housing conditions Lack of medical supplies to treat wound Poverty No funds for purchase Lack of income Economic policies Rental prices Low Education level 11 Parents unable to supervise Immigration policies

15. Where’s Public Health? 15 Transportation Agriculture Arts Housing Community Development Transportation Labor & Workforce Energy Environment Public Works Public Health Forestry & Fire Criminal Justice Finance

16. We Need a New Approach  Current decision-making tends to be Siloed Focused on a single goal or mandate Top-down Short-term in orientation Unable to address “wicked” problems

17. The HiAP Concept We all have a role to play in creating healthy communities.  Environments in which people live, work, study and play impact health  Decisions made by “non-health” agencies play a major role in shaping environments  Consideration of health allows agencies to make more informed policy and program decisions and to identify win-wins

18. What is Health in All Policies? A collaborative approach to improving the well-being of all people by incorporating health, equity, and sustainability considerations into decision-making across sectors and policy areas.

19. Many opportunities to apply a health lens  Laws and regulations  Purchasing & procurement  Grants & contracts  Guidance & best practices  Education, information, training, and technical assistance  Data, research, program evaluation  Employer  Convener  Taxes, fees, subsidies, financial incentives  Permits & licenses  Direct Services 19

20. Where do we start? Setting priorities  What is the size of the problem?  What is the seriousness of the problem?  What is the potential for interventions to impact the public’s health?  PEARL Propriety: is the intervention suitable? Economics: does it make economic sense to address the problem? Acceptability: will the community accept emphasis on this problem and the intervention? Resources: are funding and other resources available or potentially available? Legality: do current laws allow or is it worth the energy to change laws or regulations? 20 Vilnius D, Dandoy S. A Priority Rating System for Public Health Programs.(1990)Public Health Reports; 105(5):463-470

21. Establishing a Shared Vision Aspirational Goals All California residents:  have the option to safely walk, bike, or take public transit to school, work, and essential destinations  live in safe, healthy, affordable housing  have access to places to be active, including parks, green space, and healthy tree canopy  are able to live and be active in their communities without fear of violence or crime  have access to healthy, affordable foods at school, at work, and in their neighborhoods  California’s decision makers are informed about the health consequences of various policy options during the policy development process 21

22. Informal Criteria for Priority-Setting 22 recommendations  Co-benefits and nexus with other Strategic Growth Council objectives  Population health impact  Equity impact  Feasibility  Evidence-informed  Ability to engage members and stakeholders  Ability to foster collaboration among State agencies and stakeholders  Ability to measure  Ability to transform State government culture 22

23. Report to the Strategic Growth Council Topic areas Active transportation Housing and indoor spaces Parks, urban greening, and places to be active Community safety through violence prevention Healthy food Healthy public policy 

24. Priorities in Practice 11 implementation plans  Is it within our scope?  Is there enthusiasm & passion?  Is there low-hanging fruit?  Are there resources to leverage?  Other activities or processes to leverage?  Will it help to strengthen relationships?  Are there conflicts? 24 http://sgc.ca.gov/s_abouthiaptaskforce.php

25. Active Transportation  http://sgc.ca.gov/docs/Active_Transportation_Action_Plan_9-26-14.pdf

26. Housing and Indoor Spaces  Promote sustainable development through smart housing siting  Develop recommended processes for balancing multiple public policy objectives affecting air quality and the permit processing and siting of transit-oriented development  Parks, Urban Greening, & Places to Be Active   Support urban greening and access to green spaces  Fruit trees, orchards, school and community gardens

27. Healthy Food  Encourage and expand the availability of affordable and locally grown produce through “farm-to-fork” policies and programs 

28. Community Safety   Provide guidance on Crime Prevention through Environmental Design 28

29. Healthy Public Policy  Incorporate health and equity indicators into data collection and accountability measures  Standardize data elements and measures  Incorporate a health and health equity perspective into state guidance, surveys, technical assistance documents, and grant applications and scoring where feasible and appropriate  General plans  Regional transportation plans  Strategic Growth Council grants programs 

30. Healthy Community Indicators  Mirror “Healthy Community Framework”  Core, standardized measures for local use  Website with measures, data links, evidence 30 http://www.cdph.ca.gov/programs/Pages/HealthyCommuni tyIndicators.aspx#DataIndAv

31. Key Elements of HiAP  Promotes health, equity, & sustainability  Supports intersectoral collaboration  Benefits multiple partners  Engages external stakeholders  Creates structural or process change

32. What will it take?  Institutionalization Resources, organizational structures, process change, legal and executive mandates  Substantive community and stakeholder engagement  Societal and government prioritization of health, equity, and sustainability  Leadership and political will  Robust democracy & social movements

33. Support Movement Building 33

34. Key Take Home Messages  Know what you want  Be opportunistic  Relationships are the heart of HiAP (but)  Power is important  Context and structure matter  Use inside-outside strategies  Balance pragmatism and bold vision 34

35. 35 “Climate change is the defining health challenge of our time.” Margaret Chan, World Health Organization “Climate change threatens our fragile existence on this planet.” Jim Kim, World Bank " Social injustice is killing people on a grand scale.” WHO Commission on the Social Determinants of Health, 2008

36. Thank you. Linda Rudolph, MD, MPH Public Health Institute linda.rudolph@phi.org linda.rudolph@phi.org https://www.apha.org/~/media/files/pdf/fact%20sheets/ healthinallpoliciesguide169pages.ashx