Mid-level activism, informal networks and the bureaucratic politics of Health in all Policies

Introduction

Scholars of Health in All Policies note the literature's dearth of implementation-based analysis. We do not know how the generic model meets bureaucratic reality, and have not sufficiently scrutinized processes, contexts, barriers and opportunities.

Goals

We address this gap by studying Israel's HiAP-based national program to promote healthy lifestyle and curb obesity. We aimed to analyze stakeholders and networks, and complement HiAP's literature with the tacit knowledge of those charged with implementation.

Method

We conducted three years of ethnographic fieldwork alongside mid-level managers leading the program's implementation, combining observation, interviews and document analysis.

Findings

Amidst budget cuts, broken commitments and contested legislation, the team we studied relied upon informal alliances, "hid" budgets for oft-materializing "rainy days," framed policies differently according to audience, strategically credited superiors and passed information to NGOs to protest cutbacks. These strategies are not highlighted in the literature, but each proved critical.

Conclusion

The literature's emphasis on systematic frameworks suggests that health governance is a formulaic, technical endeavor. For the civil servants in our study, though, it was primarily a human one.

Four takeaways: (1) HiAP "happens" at public service's mid, not high level. (2) Informal alliances are more significant than formal ones. (3) Health authorities need to be willing to be invisible, and let others lead. (4) Public health civil servants are political actors, interpreters of people and context. Their ingenuity – what they do with the governance frameworks they receive – demand our attention, and are the heart of the struggle to foster health through HiAP.