MAP Centre for Urban Health Solutions, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
Department of Health Sciences, Wilfrid Laurier University, 75 University Avenue West, Waterloo, ON, N2L 3C5, Canada.
Int J Equity Health. 2022 Aug 15;21(1):108. doi: 10.1186/s12939-022-01703-7.
In 2008, Ecuador introduced Plan Nacional para el Buen Vivir (PNBV; National Plan for Good Living), which was widely recognized as a promising example of Health in All Policies (HiAP) due to the integration of policy sectors on health and health equity objectives. PBNV was implemented through three successive plans (2009-2013, 2013-2017, 2017-2021). In a time of widening global health inequities, there is growing interest in understanding how politics and governance shape HiAP implementation. The objective of this study was to test specific hypotheses about how, why, to what extent, and under what circumstances HiAP was implemented in Ecuador.
An explanatory case study approach (HiAP Analysis using Realist Methods on International Case Studies-HARMONICS) was used to understand the processes that hindered or facilitated HiAP implementation. Realist methods and systems theory were employed to test hypotheses through analysis of empirical and grey literature, and 19 key informant interviews. This case study focused on processes related to buy-in for a HiAP approach by diverse policy sectors, particularly in relation to the strong mandate and transformative governance approach that were introduced by then-President Rafael Correa's administration to support PNBV.
The mandate and governance approach of the HiAP approach achieved buy-in for implementation across diverse sectors. Support for the hypotheses was found through direct evidence about buy-in for HiAP implementation by policy sectors; and indirect evidence about allocation of governmental resources for HiAP implementation. Key mechanisms identified included: influence of political elites; challenges in dealing with political opposition and 'siloed' ways of thinking; and the role of strategies and resources in motivating buy-in.
In Ecuador, political elites were a catalyst for mechanisms that impacted buy-in and government funding for HiAP implementation. They raised awareness among policy sectors initially opposed to PNBV about the rationale for changing governance practices, and they provided financial resources to support efforts related to PNBV. Specific mechanisms help explain these phenomena further. Future studies should examine ways that PNBV may have been an impediment to health equity for some marginalized groups while strengthening HiAP implementation.
2008 年，厄瓜多尔推出了“美好生活国家计划”（PNBV），该计划因整合了卫生和健康公平目标相关政策部门，被广泛认为是“全健康政策”（HiAP）的一个有前途的范例。PNBV 通过三个连续的计划（2009-2013 年、2013-2017 年、2017-2021 年）实施。在全球卫生不公平现象不断扩大的时代，人们越来越感兴趣地了解政治和治理如何影响 HiAP 的实施。本研究的目的是检验关于 HiAP 在厄瓜多尔实施的方式、原因、程度和情况的具体假设。
采用解释性案例研究方法（使用国际案例研究中的真实主义方法分析全健康政策-HARMONICS）来了解阻碍或促进 HiAP 实施的过程。真实主义方法和系统理论被用来通过分析经验和灰色文献以及 19 次关键知情人访谈来检验假设。本案例研究重点关注与不同政策部门对 HiAP 方法的认可相关的过程，特别是与当时总统拉斐尔·科雷亚的政府引入的强有力的授权和变革性治理方法有关，该方法支持 PNBV。
HiAP 方法的授权和治理方法在不同部门实现了实施的认可。通过政策部门对 HiAP 实施的认可的直接证据，以及对 HiAP 实施的政府资源分配的间接证据，发现了对假设的支持。确定的关键机制包括：政治精英的影响；处理政治反对派和“筒仓”思维方式的挑战；以及策略和资源在激励认可方面的作用。
在厄瓜多尔，政治精英是影响政策部门对 HiAP 实施的认可和政府资金投入的机制的催化剂。他们使最初反对 PNBV 的政策部门对改变治理实践的理由有了认识，并为与 PNBV 相关的努力提供了财政资源。具体机制进一步解释了这些现象。未来的研究应研究 PNBV 如何在加强 HiAP 实施的同时，对一些边缘化群体的健康公平造成障碍。
