加强'将健康融入所有政策'的实施:基于现实主义的解释性案例研究

摘要

To address macro-social and economic determinants of health and equity, there has been growing use of intersectoral action by governments around the world. Health in All Policies ( HiAP) initiatives are a special case where governments use cross-sectoral structures and relationships to systematically address health in policymaking by targeting broad health determinants rather than health services alone. Although many examples of HiAP have e-merged in recent decades, the reasons for their successful implementation-and for implementation failures-have not been systematically studied. Consequently, rigorous evidence based on systematic research of the social mechanisms that have regularly enabled or hindered implementation in different jurisdictions is sparse. We describe a novel meth-odology for explanatory case studies that use a scientific realist perspective to study the implementation of HiAP. Our methodology begins with the formulation of a conceptual framework to describe contexts, social mechanisms and out-comes of relevance to the sustainable implementation of HiAP. We then describe the process of systematically explai-ning phenomena of interest using evidence from literature and key informant interviews, and looking for patterns and themes. Finally, we present a comparative example of how Health Impact Assessment tools have been utilized in Swe-den and Quebec to illustrate how this methodology uses evidence to first describe successful practices for implementa-tion of HiAP and then refine the initial framework. The methodology that we describe helps researchers to identify and triangulate rich evidence describing social mechanisms and salient contextual factors that characterize successful prac-tices in implementing HiAP in specific jurisdictions. This methodology can be applied to study the implementation of HiAP and other forms of intersectoral action to reduce health inequities involving multiple geographic levels of govern-ment in diverse settings.%目前,世界各国普遍采取跨部门行动解决健康的宏观社会和经济决定因素. "将健康融入所有政策( HiAP)"是各国采取跨部门行动的策略之一,它以广义的健康决定因素而非单纯的卫生服务为目标,在决策过程中系统解决健康问题. 近几十年来出现了很多关于HiAP的案例,但这些案例成功或失败的原因并未得到系统的研究,这就导致以证据为基础的有关促进或阻碍HiAP策略实施的相关因素的研究较少. 本文基于现实主义视角,采用解释性案例研究,分析了不同地区HiAP策略的实施情况. 本研究在提出概念性框架的基础上,分析了与HiAP可持续实施有关的背景、社会机制及结果,并利用相关文献以及从关键知情人访谈中得到的证据,寻找相关的模式和主题对现象加以解释. 最后,通过对瑞典和加拿大魁北克实施卫生影响力评估的情况进行比较,揭示了HiAP成功实施的经验. 此方法能够帮助研究者对某一地区内成功实施HiAP的社会机制和背景因素的大量证据信息加以审核并做三角测量,还可用于分析其他形式的部门间行动,以减少不同背景、不同地区之间的卫生不公平性现象.