HiAP in Adelaide
Health in All Policies (HiAP) is a way of governing that asks every government department, not just the health sector, to pause and consider how its decisions will affect people’s health and well-being (WHO, 2014; Williams & Galicki, 2017). Cities are where this plays out most clearly, because local governments control many of the “big levers” that shape daily life, urban planning, housing, transport, and public spaces (UN-Habitat, 2021; Williams & Galicki, 2017). Many cities have tried pieces of this approach, but Adelaide is distinctive. Over more than a decade, it has moved from scattered, one-off projects to embedding HiAP into the law (Baum et al., 2019; Williams & Galicki, 2017). Adelaide’s experience shows how putting health into legislation can turn short-lived political promises into something more durable.
Adelaide offers a rare, long-term example of a city that has systematized HiAP and maintained it through economic downturns and changes in political leadership (Baum et al., 2017; Williams & Galicki, 2017). The South Australian Public Health Act 2011 is the clearest sign of this commitment, requiring local councils to develop Regional Public Health Plans, giving HiAP a firm legal base rather than leaving it to goodwill alone (Baum et al., 2019; Williams & Galicki, 2017). Tools such as the Health Lens Analysis (HLA) and 90-Day Projects bring people from different departments together to co-design responses to concrete challenges, such as Aboriginal road safety and children’s literacy (Baum et al., 2019; Williams & Galicki, 2017). Adelaide’s leadership has also been recognized globally through the 2010 and 2017 Adelaide Statements on Health in All Policies (WHO & Government of South Australia, 2017). A five-year evaluation by the Southgate Institute found that these efforts helped build a more collaborative “One Government” culture, where health became a shared concern and a common language across the public service (Baum et al., 2019; Southgate Institute, 2017).
Embedding health in everyday government processes matters more than launching short-term programs. It helps protect HiAP from “policy myopia,” the tendency to pursue quick political wins rather than invest in long-term population health (Van Eyk et al., 2017; Williams & Galicki, 2017). By weaving health considerations into the fabric of the bureaucracy, Adelaide ensured that these concerns would outlast changes in leadership and financial pressures (Baum et al., 2019; WHO, 2023). For example, when a new Premier took office, or budgets were under strain, a formal Memorandum of Understanding (MOU) with the Department of the Premier and Cabinet provided high-level backing that helped keep HiAP visible and legitimate across agencies (Baum et al., 2017; Williams & Galicki, 2017).
This formal structure also helped reduce resistance from non-health sectors. Instead of being dismissed, HiAP was presented as a practical way for other departments to meet their own strategic goals through a “co-benefits” approach (Baum et al., 2017; Van Eyk et al., 2017). The creation of Public Health Partner Authorities (PHPAs) formalized these win-win relationships, making collaboration a legal mechanism for mutual benefit rather than an extra favor asked of busy agencies (WHO, 2023; Williams & Galicki, 2017). Over time, this institutionalization helped shift health from something seen as external to other sectors’ work into a shared currency across the public service (Baum et al., 2019; Williams & Galicki, 2017).
Beyond the legal framework, the “co-benefits” strategy ensured that departments such as transport, housing, and education saw HiAP as a means to meet their own targets, rather than as an additional demand from the health sector (Van Eyk et al., 2017; Williams & Galicki, 2017). The primary tool for this was the Health Lens Analysis (HLA), a five-stage process (engage, evidence, generate, navigate, and evaluate) that brings different actors together to develop policy solutions (Baum et al., 2019; Williams & Galicki, 2017).
This move away from siloed delivery was only possible because of a distinctive administrative culture led from the very top. Successive Premiers and the Department of the Premier and Cabinet treated health not only as a cost to be managed, but as an asset that could strengthen economic, social, and environmental outcomes (Baum et al., 2017; Williams & Galicki, 2017). By explicitly linking HiAP to the “triple bottom line,” they kept the initiative relevant even in times of tight budgets, when programs without clear economic or social payoffs are especially vulnerable (Van Eyk et al., 2017; Williams & Galicki, 2017).
Building on this, the five-year study conducted from 2012 to 2017 by the Southgate Institute offers data on how the initiative truly made a difference (Baum et al., 2019). It showed a positive shift in bureaucratic mindset, with 53.2% of public servants reporting a better understanding of health equity and 55.4% seeing clear connections between their work and social factors (Baum et al., 2019). However, the inequality rate ratio in South Australia grew from 1.57 (1987–1991) to 2.05 (2010–2014) during the HiAP era (Van Eyk et al., 2017). Even more, despite its high-level goals, HiAP operated on a tiny annual budget of $550,000, which is just 0.00948% of the state's health budget (Baum et al., 2019; Williams & Galicki, 2017). In the end, the study’s program logic suggested that while HiAP helped improve government processes, it didn’t make a noticeable dent in reducing health inequalities in life expectancy (Baum et al., 2019).
Despite these strengths, a major weakness in Adelaide’s current HiAP approach is that the equity agenda has become almost invisible (Van Eyk et al., 2017). To maintain intersectoral buy-in, the HiAP team often emphasized “co-benefits” and avoided explicit equity language, worried that such language might sound like technical health jargon and put partners off (Van Eyk et al., 2017). The risk is that when equity is left implicit, it can quickly slip down the priority list during economic downturns or political change (Baum et al., 2019; Van Eyk et al., 2017). One way to address this would be to amend the South Australian Public Health Act 2011 to explicitly require regulated Health Equity Impact Assessments (HEIAs) for major policy proposals (Baum et al., 2017). This would turn equity into a clear, legal obligation for all agencies and ensure that how resources are distributed is assessed and reported transparently, no matter who is in power (Baum et al., 2017; WHO, 2023).
Alongside legislative reform, a second key recommendation is to bring into decision-making the people most affected by policy but often missing from the table, community members and Indigenous peoples (Baum et al., 2019; Van Eyk et al., 2017). At present, Adelaide’s HiAP model relies heavily on consensus among senior officials, with relatively few structured opportunities for citizen voice (Baum et al., 2019). Deepening Indigenous participation is especially important for equity, since Indigenous health is closely tied to land, culture, and ongoing experiences of colonization (Adelaide Statement, 2010; WHO, 2023). Tools such as citizens’ juries, participatory budgeting, and formal Indigenous leadership roles within HiAP structures could help shift this balance (WHO, 2023; Adelaide Statement II, 2017). Expanding participation in these ways would make HiAP both fairer and more effective, moving from a largely top-down model to one in which solutions are co-created with communities that live with the consequences of policy decisions (WHO, 2023). Over time, this could help build a broader social mandate for HiAP, one strong enough to confront and reshape the structural inequities that drive poor health (Baum et al., 2019; WHO, 2023).
References
Baum, F., Delany-Crowe, T., MacDougall, C., Lawless, A., Van Eyk, H., & Williams, C. (2017). Ideas, actors and institutions: Lessons from South Australian Health in All Policies on what encourages other sectors’ involvement. BMC Public Health, 17(1), 811.
Baum, F., Delany-Crowe, T., MacDougall, C., Van Eyk, H., Lawless, A., Williams, C., & Marmot, M. (2019). To what extent can the activities of the South Australian Health in All Policies initiative be linked to population health outcomes using a program theory-based evaluation? BMC Public Health, 19(1), 88.
Southgate Institute for Health, Society and Equity. (2017). Does a Health in All Policies approach improve health, well-being, and equity in South Australia? Policy Brief. Flinders University.
UN-Habitat. (2021). Leveraging Multi-Level Governance Approaches to Promote Health Equity: A Guide. United Nations Human Settlements Programme.
Van Eyk, H., Harris, E., Baum, F., Delany-Crowe, T., Lawless, A., & MacDougall, C. (2017). Health in All Policies in South Australia—Did it promote and enact an equity perspective? International Journal of Environmental Research and Public Health, 14(11), 1288.
Williams, C., & Galicki, C. (2017). Health in All Policies in South Australia: lessons from 10 years of practice. South Australian Department for Health and Ageing.
World Health Organization. (2014). Health in all policies: Helsinki statement. Framework for country action. World Health Organization.
World Health Organization. (2023). Working together for equity and healthier populations: Sustainable multisectoral collaboration based on Health in All Policies approaches. World Health Organization.
World Health Organization & Government of South Australia. (2010). Adelaide Statement on Health in All Policies: Moving towards a shared governance for health and well-being.
World Health Organization & Government of South Australia. (2017). Adelaide Statement II on Health in All Policies: Implementing the Sustainable Development Agenda through good governance for health and well-being.
