Health in All, Health for All: Promoting Active, Healthy Lifestyle in Israel with HiAP

In December 2011, the Israeli government, municipalities and civil society joined together to launch the National Program to Promote Active, Healthy Lifestyle.  In the following post, we present the program, describe where it echoes Health in All Policies, identify HiAP-inspired directions we aim to pursue and raise questions that accompany us midway through the program’s second year. A detailed version can be found here.

Obesity levels have increased steadily in Israel over the last four decades, more drastically among individuals of lower socio-economic status. 50% of the adults and 20% of our children are overweight or obese. More than 3,000 Israelis die every year because of obesity and chronic disease. Costs add up to six billion shekels per year.

Less than a third of Israeli adults engage in the recommended amount of physical activity. Our children are among the least physically active, and spend more time playing computer games, than children in almost all other countries in the WHO’s Health Behavior among School Children (HBSC) survey. All segments of the population consume sweetened drinks every day. Average salt intake is more than double the recommended level. In the past, we have eaten enough fruits and vegetables. Recent evidence, though, suggests a decrease, especially among low income groups.

In short, we’ve become sedentary, do not eat as healthfully as we should and it’s making us sick. In order to address the challenge, the Government’s Social and Economic Affairs Cabinet adopted the National Program. Led by the Ministries of Health, Education and Culture & Sport, the program’s aims are to foster health promoting environments in the settings that comprise Israeli life, enhance our population’s understanding of what it takes to be healthy and incentivize organizations and municipalities to promote health.

Legislative initiatives include removing junk foods from schools, providing tax breaks on workplace purchases of healthy refreshments, lifting a requirement to obtain a doctor’s permission to join a health club, banning junk food ads during children’s TV, requiring restaurants to calorie-label menus and mandating front-of-package food labeling. The Ministries of Health and Finance are working together to identify economic interventions to make healthy foods more accessible and/or unhealthy foods more expensive.

The Ministry of Education declared 2011-12 to be “The Year of Active, Healthy Lifestyle.” Schools appointed councils of health-promoting students, and 85 schools gained accreditation as health-promoting schools. Another 100 will be recognized in 2013. The Ministry added health promotion to its list of educational objectives and launched a fruit and vegetable scheme with the Ministries of Agriculture and Health.

15 municipalities are participating in the “Municipalities Promoting Active, Healthy Lifestyle” program. In addition to creating opportunities for all to engage in active, healthy lifestyle, each municipality must affect policy change at public institutions, community centers and schools. In parallel, the National Program is strengthening Israel’s Healthy Cities Network, via added cities and funding for local and national staff.

Incentives for Israel’s four health providers include rewards for hiring health promoters and providing guidance for chronically ill and/or overweight patients and their families. The Health Ministry has oriented district offices’ health promotion programs to focus on active, healthy lifestyle, including programs like health-promoting nursery schools and women’s walking groups. NGO-led programs include active transportation to school, edible gardens in nursery schools and providing bicycles and training to disadvantaged youth.

Finally, the Health Ministry is (cautiously) working with the food industry to reduce salt content in processed foods and fortify flour for the Bedouin community, which suffers from malnutrition and high infant-mortality. Additional initiatives include a game-based website for children, health-related content for children’s TV, health promotion in the military and the police and a healthy workplaces pilot set to begin in 2013. The National Program also includes Israel’s largest ever social marketing program, with a focus on both social media and community-based social marketing.

THE COLLABORATIVE nature of the National Program is its defining characteristic. The choice to share leadership with the Ministries of Education and Culture & Sport reflect the Health Ministry’s recognition of the fact that HiAP’s success is, in part, a function of the extent to which non-health sectors own a stake in the process. The program therefore includes several examples of budget-sharing between ministries. Legislative progress has often depended on engaging stakeholders, like the Israeli Union of Restaurateurs, national councils of family doctors and pediatricians and television networks.

Governance structures include an intergovernmental steering committee, and committees charged with workplace health promotion and identifying regulatory measures to encourage healthy eating. An illustration of the National Program according to the WHO’s recently published Analytical Framework for Intersectoral Governance can be found here.

While aspects of the National Program resonate with HiAP, we have identified the following steps to strengthen the program’s intersectoral potential:

A first step: Strengthening the intersectoral steering committee. This committee was intended to lead the National Program. In practice, it became a forum for status updates between members of the Health Ministry, while other ministries played passive roles. This must change in order to facilitate a health-promoting cross-governmental agenda.

Another step: The Health Ministry participates in committees which address issues like food imports, agriculture and urban planning. These memberships should be leveraged to coordinate policies which promote healthy lifestyle. More broadly, our presence in such forums can be utilized to defend values which promote health equity, like access to services, community, environmental justice and fair housing. We must step out of our “health box” to become acquainted with other policymaking environments, in order to identify additional “win-win” situations between sectors and strengthen the networks that anchor HiAP.

We must focus on knowledge translation. Health information should be accessible to and disseminated toward non-health sectors, synthesized and framed according to their language and policymaking needs. Health Impact Assessment, for example, can be utilized to build a common language between health and other sectors, as shown in this study. A panel of experts from Israel’s five universities as well as the Ministries of Health, Education and Culture & Sport are leading the National Program’s evaluation. Academic representatives from outside of health should be added. In addition, the Ministry of Environmental Protection and the National Economic Council are leading an effort to design an indicator of national wellbeing beyond GDP – the National Program can strengthen this effort, as well.

18 months into the National Program’s implementation, questions remain: How, why, where and when is each sector the most/least responsive? How important is informal collaboration? Does joint budgeting lead to more or less financial support for health promotion? How can evidence be framed in order to turn the Finance Ministry into an advocate? Each sector has its own needs and is entrenched in its own policy narratives. To what extent will the health sector adapt to these needs? Finally, how will the Health Ministry address the clear risks of collaborating with the food industry?

Health Ministry workers will be impacted by the HiAP approach, as well. To what extent will intersectoral action distract from competing responsibilities? Will the Health Ministry equip its staff with the skills to engage beyond health? Clearly, there is a need to strike a balance between fulfilling health’s classic roles and exploring unchartered policy terrain.

The National Program to Promote Active, Healthy Lifestyle represents a paradigm shift for the Ministry of Health, featuring unprecedented investment in public health and health promotion and opening new channels for fostering population-wide health. Alongside HiAP efforts worldwide and inspired by an incredible population at home, we are excited to continue moving forward.

Further reading:

Kranzler Y, Davidovitch N, Fleischman Y, Grotto I, Moran D, Weinstein, R: A health in all policies approach to promote active, healthy lifestyle in Israel. Israel Journal of Health Policy Research 2013, 2:16. http://www.ijhpr.org/content/2/1/16

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