Public Health from the Middle-Out: A New Analytical Perspective.

Obstacles to collaborative public health frameworks such as Health in All Policies continue to emerge. Partnership-based public health programs present opportunities to study how public servants and practitioners address these barriers in real time. To this end, we utilized "Middle-Out," a socio-technical analytical approach that highlights the importance of Middle Actors-stakeholders positioned between policymakers and grassroots-to policy diffusion, innovation and collaboration in public health. We conducted participatory observation in administrative settings of Israel's National Program to Promote Active, Healthy Lifestyle, 30 stakeholder interviews and document analysis. We examined two dimensions of impact from the Middle-Out: Directions of Influence-Middle-Up, Middle-Down and Sideways, and Modes of Influence-Enabling, Mediating and Aggregating. Through Middle-Out's lens, our analysis transcends visible benchmarks such as legislation and macro-level resource-allocation, focusing, instead, on elusive administrative spaces within which Middle Actors shape policies, steer funding and facilitate continuity. Incorporating Middle-Out into public health's conceptual toolbox, we conclude, can improve understanding of complex public health policy arenas, increase recognition of critical socio-technical changemakers and catalyze more effective design of policy tools and strategies that specifically harness Middle Actors' strengths and qualities.

A health in all policies approach to promote active, healthy lifestyle in Israel.

In December 2011, Israel launched the National Program to Promote Active, Healthy Lifestyle, an inter-ministerial, intersectoral effort to address obesity and its contribution to the country's burden of chronic disease. This paper explores the National Program according to the "Health in All Policies" (HiAP) strategy for health governance, designed to engage social determinants of health and curb health challenges at the causal level. Our objective is twofold: to identify where Israel's National Program both echoes and falls short of Health in All Policies, and to assess how the National Program can be utilized to enrich the Health in All Policies research-base.We review Health in All Policies' evolution, why it developed and how it is diverges from other approaches to intersectoriality in health. We describe why obesity and related chronic diseases necessitate an intersectoral response, cite obstacles and gaps to implementation and list examples of HiAP-type initiatives from around the world. We then analyze Israel's National Program as it relates to Health in All Policies, and propose directions through which the initiative may constitute a useful case study.We contend that joint planning, implementation and to a limited extent, budgeting, between the Ministries of Health, Education and Culture and Sport reflect an HiAP-approach, as does integrating health into the policymaking of other ministries. To further incorporate health in all Israeli policies, we suggest leveraging the Health Ministry's presence on governmental and non-governmental committees in areas like building, land-use and urban planning, institutional food policy and environmental health, and focusing on knowledge translation according to the policy needs, strengths and limitations of other sectors. Finally, we suggest studying the National Program's financing, decision-making and evaluation mechanisms in order to complement existing research on the implementation of Health in All Policies and intersectoral action for health.