Introduction

Recent stressors, such as the COVID-19 syndemic and the effects of climate change, are driving many governments towards a public health model in which political leaders serve as lead strategists, partnering with multiple sectors and leveraging data and resources to address the social, environmental and economic conditions that affect well-being and health equity. This criteria has increased dramatically since 2020 [1] as it seeks to make sense of the management of health policy, of the policy process, and also of the inter-organisational relationships that explore addressing the consequences of the developing economic, social and environmental crisis [2,3].

Are policy actors and institutions in a position to embrace and incorporate changes that affect public health and health/well-being policy-making, and vice versa? Undoubtedly, finding new reference points to guide these processes is an absolute necessity; however, the road is still long and rough to ensure a more favourable environment and thus disseminate and scale up this model. This manuscript aims to provide some ideas, reflections and strategies to strengthen and develop future public action in this regard.

We consider it appropriate to distribute the content of the document under several headings so that all the general orientations, as well as the ideas put forward, constitute a renewed call for debate and public consultation by various actors. In this sense, we start from a conceptualisation of public health related to its trans-sectoral nature. Secondly, we develop a justified perspective of a political science approach to public health policy as well as the challenges and opportunities for integrating both disciplines that can ensure their institutionalisation in decision-making, the convergence towards this model and the redefinition of the roles played by the actors involved in this process for the full exercise of shared commitments.

Our main objective in this paper is to initiate a vigorous and constructive debate on how a comprehensive agenda for the 21st century could be framed to promote even greater progress in public health than has been achieved so far.

Methods

An interpretative synthesis method was used to conduct the review. Interpretive syntheses use systematic and empirical procedures to combine both qualitative and quantitative forms of research [4].

Search strategy and inclusion criteria

Google Scholar and relevant bibliographies were searched in English and Spanish for quantitative, qualitative, or mixed-method research. The study was grounded in our initial question: Are policy actors and institutions in a position to embrace and incorporate changes that affect public health and health/well-being policy-making, and vice versa? A total of 439 studies were included in the larger review.

Data subtraction

Using Covidence software, the following information was extracted for each article: objective of the research, main findings and supporting evidence, limitations of the study, and recommendations for public health practice, policy and future research. For the qualitative studies, we also drew additional information related to the development of focus group discussions, coding methodology, and theoretical frameworks used in the research.

Data integration

We imported the 439 articles into Atlas.ti and performed a full-text search to identify likely relevant articles based on preliminary inductive codes, this process resulted in the selection of 41 manuscripts. The main objective of the coding was to extrapolate constructs from the results sections to develop categories that capture the various results presented in the 41 studies as succinctly and efficiently, but also as comprehensively as possible of the findings related to 3 general themes: a) the political character of public health policy; b) public health policy: the rationale for a policy approach; and c) challenges and opportunities for integrating public health and political science.

Formulation of a synthesis argument

To conclude, we developed a coherent and interrelated synthesis argument that allowed us to initiate a critical and constructive debate on how a public health agenda integrated with political science could be framed.

Results and Discussion

The political character of public health policy

Public health is the policy response of government and communities and their structures to mitigate the economic, environmental and social factors that cause inequities and minimise citizens' health/quality of life opportunities; It is therefore an eminently societal process operating in the territory in which the biology of the human body intersects with psychology, sociology, economics, politics, geography and others [5].

Public health, like politics, is a right that is achieved when individuals recognise that their real and felt needs and desires are shared with others and demand-through public opinion-that the tate guarantee attention that is consistent with those concerns [6]. Moreover, both respond to intrinsically interdisciplinary and multi-sectoral purposes that bring together professional expertise and practices in diverse areas to interact on health/well-being inequities, focusing on health promotion and addressing all its determinants: political, commercial, social, environmental, genetic, systemic and cultural [7,8].

However, over time, public health advocates have allowed themselves to be cornered by a 'medicalised' language that has resulted in a difficult articulation between evidence, theory and practice as if they were not modulated by multiple real-world values to ensure the conditions in which we can all be healthy [9,10] and which could be optimised by creating a more inclusive and transparent culture, doctrinal approaches and professional development pathways underpinned by political science [11].

Despite these approaches, the 'public health community' has so far been remarkably weak on the analysis of formal and informal political action; for all that the policy causes on the processes as well as the influence of political institutions and political systems-including political parties, interest groups and social movements-and on what synergy with political science can mean for most of the more pressing challenges we see today. Failure to critically analyse the political context, including rights, ideologies and norms, can lead 'specialists' to bias their research and practice, specifically on issues of public policy design and governance for health/wellbeing [12,13].

Public health policy: the rationale for a policy approach

In reviewing the definitions of public health policy, the following characteristics can be identified: firstly, it is part of a structure of a formal state or government authority, which includes various social actors with competencies and responsibilities in the field being decided upon. Secondly, they are understood as a process that articulates decisions, objectives or goals to achieve planned or envisioned changes in the social, political and institutional system; modifying its forms of action, relationship or governance. Third, public policies integrate resources, visions, values, ideological or pragmatic frameworks through negotiations and compromises and are therefore a process of social mediation that involves dialogue and deliberation, adding the potentialities of the actors involved, in order to bring together the solution alternatives that originate the fundamental needs of the communities; the gaps between sectors, between society and sectors and between government-State and society [14]. This concept infers three basic meanings to be considered for the integration of political science and public health: public policy conceived as the sphere of action of government and human societies; public policy as the activity of organisation and struggle for the control of power; and finally, public policy as the designation of the purposes and programmes of public authorities [15].

Analysing these key arguments, we might conclude that in a comprehensive public health policy: (a) policy is not an intervention, but drives the development and implementation of public health interaction; (b) understanding of policy processes and their relevant theories are fundamental to the potential for influencing public health change; (c) those theories and associated empirical work must recognise the multilevel and incremental 'wicked' nature of the 'power' behind the elements in the process; and, therefore, (d) the toolbox of public health policy research, implementation and monitoring should more explicitly embrace political science knowledge from a critical perspective in order to implement more coherent and coordinated actions [16]. In this sense, policy integration would involve the horizontal and vertical combination of policy objectives and instruments from different sectors so that they can produce a coordinated and complementary response to the well-being of citizens, with a strong commitment to equity as well as social justice [17].

A growing recognition that public health policies need not only adequate policy options, but also how policy and policy-making processes can have an impact on their possible implementation, would help to set better expectations and make the demands required for issues that are being ignored to be recognised and would have a significant impact on the quality of life of the population [18].

Challenges and opportunities for integrating public health and political science

As described above, because public health is political, it makes sense to draw on the insights of political science to systematically understand how public health works within government and communities. However, it is a relatively underdeveloped area, in part because of structural barriers that prevent these two disciplines from engaging in a meaningful way.

These barriers, analytically, arise as the public health community deploys theories and concepts from political science to better understand not only what governments choose to do, but also why and how they do it. Similarly, they are normative obstacles insofar as they draw on political science to explain how they can make more effective claims about what governments should do and research in relation to good public health policy [19].

In this vein, several authors have pointed out, firstly, the lack of a common language and shared understanding of the key principles of each discipline; indeed, many of the pathways leading to public health impact are political, although the precise structures by which they are governed differ in their interpretations: public health specialists insist on making political decisions based exclusively on scientific evidence; on the other hand, politicians also recognise the importance of scientific research, but are more open to other aspects that need to be taken into account, such as ideological factors. Secondly, it is important to recognise the complexity and diversity within each field; at present, both are viewed through a narrow lens where traditional public health research relies on a limited set of models and tries to apply them in a simplified way while policy makers tend to merge perceptions of policy. Third, for political science is axiomatic that governments must balance and reconcile multiple overarching goals and objectives when deciding policy; in addition to health issues, decision-makers must weigh economic and environmental challenges, to name only two; while for public health experts, health considerations must be the predominant determinants of public policy decisions. Finally, the political science perspective of centring the public health function within the wider machinery of government is presented, as opposed to the public health interest in using the roles and responsibilities of public health actors to lead social and political change [13,20,21].

On a practical level, in the face of today's complex political, social, economic and environmental challenges, some actions will remain "traditional" in public health; other actions will be more tactical and require multi-faceted and multi-level interventions involving both vertical and horizontal integration with political science, and the challenge is to implement them. In this context, a number of strategies have been proposed that could help overcome the impasse [22].

• Expand social-scientific understanding of public health and political science. A conscientious and transparent approach to determining what policy is and what it implies is an essential starting point for the future development of the field, which aims to foster a new and more integrated description of public health policy that can be shared with policy makers, and to build joint capacity to contribute to reducing health inequities. This would require that professionals in both fields step out of their comfort zones and open their minds to different perspectives from both disciplines and incorporate these components during their formal training and personal development [2,23-25].
• Better connecting public health evidence with practical policy solutions. Public health practice requires more relevant and instrumental data for effective interaction with other sectors so that it can be effectively communicated and presented to policy makers, practitioners and the public in terms and with examples that they understand and accept. The challenge for both disciplines is to capitalise on the evidence, incorporating health network analysis into policy impact analysis and bringing together the views of other actors and their problem-solving alternatives to respond positively to the multiple dimensions of health/wellbeing experienced by communities [20,26].
• Recognise the plurality of interests in our societies. Political science provides concepts to help structure analyses of the influence of position, interests and power behind actors and institutions. In order to shape a more precise public health agenda, with greater opportunities for power where everyone has a better chance of being heard, new organisational cultures must be constructed that build informal networks with shared values and trust through the lens of epistemic communities or other political science approaches, transformational leadership in which the power to change is based on goals that help empower communities and other sectors to improve public health and in which governance and accountability mechanisms are participatory. [27-33].
• Redefine the roles of the actors involved in both disciplines. No single strategy is sufficient to address the gap between public health and political science in policy making; therefore, it is critical that stakeholders are clear about the goals they are trying to achieve, that they are mindful of the specific environment in which they are working, and that they are intentional about questions such as who participates, with what authority, and how this affects the legitimacy, quality and relevance of the process and outcomes [24]. In this context, there needs to be: a) a shift in the public health academic community from a medicalised view of problems to a political framing of solutions and; concomitantly, for policy makers to break out of many dependencies and make fundamental changes in aspects of practices and ways of addressing health problems and their solutions. This requires contextual adaptation led by a collective of professionals who know each other and work together in a favourable political and scientific context that fosters an inclusive perspective [21,34,35]; b) the internal structure and coalitions that underlie public health institutions often focuses on the aspirations of the sector's elites about what needs to change, rather than creating the mechanisms to achieve outcomes that promote healthy communities. The abilities to handle these situations are acquired when universities, schools of public health, medical schools incorporate in their curricula the training of interpersonal skills such as relationship building, influencing, negotiation and political astuteness to collaborate with like-minded and committed political forces; as a means to provoke deliberation with other actors on how to deal with these difficulties [36,37]; c) Relevant contextual and conceptual factors to consider when truly integrating public health with political science are related to the willingness and capacity of citizens with a culture to participate as co-designers of equitable policies. In that sense, community bonding social capital, as the solidarity networks that connect people within vulnerable communities; bridging social capital, as the networks that join groups of people who are more or less equal in terms of power and status; and linking social capital, as the networks that associate people with more powerful advocates; are fundamental elements for developing new paradigms and shared political commitment. What is most needed, then, is more attention to the important work of political science that takes place in local levels: the area where community interests and needs interact, through deliberative assemblies, alongside-and sometimes in conflict with-political and social forces; we believe that this is perhaps the most fruitful field of potential collaboration between public health and political science [25,38-42].

Conclusion

The integration and collaboration of public health and political science would benefit the quality of life in health and well-being as a whole, as such interaction is likely to result in better policies and decisions. However, there are still pernicious elements that prevent this convergence from developing effectively.

Some of these barriers relate to entrenched differences in disciplinary identities, methodologies and knowledge processes, including an enduring professional distinction between policy and science in public health, which leads many to see their mandate as dominant; the divergence between felt/real needs and policy-related processes in integrating scientific evidence; and an operational gap, with political science typically focused on governability and governance processes and public health often centered on biomedical interventions.

For these disciplines to engage more with each other, we suggest four interrelated tips: (1) better connect the understanding of public health and political science, in its social-political-institutional context, with scientific evidence and practical policy methodologies; (2) encourage sustained interactions between public health agents and institutions working on or advocating for policy solutions and political institutions that prioritise shared public health solutions; (3) enlist the help of human talent training institutions to foster knowledge, skills and competencies that engage all sectors-including private enterprise-in health in all policies approaches; and (4) promoting meaningful citizen participation in the building and development of networks that advocate policy solutions for public health.

Acknowledgements

None

Conflict of interest

Author declares that there is no conflict of interest.

References

1. Jungkunz S. Political Polarization During the COVID–19 Pandemic. Front Polit Sci. 2021;3: 622512.
2. Fafard P, Cassola A, Weldon I. Political Science In, Of, and With Public Health. In: Fafard P, Cassola A, de Leeuw E, (eds). Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Cham (Switzerland): Palgrave Macmillan. 2022. p. 15–31.
3. Leyton C. Editorial: Nuevos modelos de gestión e implementación de políticas públicas [Editorial: New models of public policy management and implementation]. Rev Est de Políticas Públicas. 2022;8(2): 1–3.
4. Depraetere J, Vandeviver C, Keygnaert I, Vander Beken T. The critical interpretive synthesis: an assessment of reporting practices. International Journal of Social Research Methodology 2021;24(6): 669–689.
5. Orme J, Powell J, Taylor P, Harrison T, Grey M. Public Health for the 21^st New Perspectives on Policy, Participation and Practice. Second Edition. Berkshire (England): Open University Press; 2007.
6. Oliver TR. The Politics of Public Health Policy. Annu Rev Public Health. 2006;27: 195–233.
7. Amri M, Chatur A, O’Campo P. Intersectoral and multisectoral approaches to health policy: an umbrella review protocol. Health Res Policy Sys. 2022;20: 21.
8. Mondal S, Van Belle S, Maioni A. Learning from intersectoral action beyond health: a meta–narrative review. Health Policy and Planning. 2021;36(4): 552–571.
9. La Valle R. Sobre medicalización. Orígenes, causas y consecuencias Parte I [About medicalization. Origin, causes and consequences Part I]. Hosp Ital B Aires. 2014;34(2): 67–72.
10. Greer SL, Bekker MPM, Azzopardi–Muscat N, McKee M. Political analysis in public health: middle–range concepts to make sense of the politics of health. European Journal of Public Health 2018;28(suppl_3): 3–6.
11. American Political Science Association. Political Science in the 21^st Washington, DC (USA): Harvard University; 2011.
12. Gore R, Parker R. Analysing power and politics in health policy and systems. Global Public Health. 2019;14(4): 481–488.
13. Gagnon F, Bergeron P, Clavier C, Fafard P, Martin E, Blouin C. Why and How Political Science Can Contribute to Public Health? Proposals for Collaborative Research Avenues. Int J Health Policy Manag. 2017;6(9): 495–499.
14. Mandl Stangl J. Health in All Policies: Management Model for the Comprehensive Transformation of the System. J Qual Healthcare Eco. 2021;4(2): 000217.
15. Roth Deubel AN. Perspectivas teóricas para el análisis de las políticas públicas: ¿de la razón científica al arte retórico? [Theoretical Perspectives for the Analysis of Public Policies: From Scientific Reason to Rhetorical Art?]. Estudios Políticos. 2008;33: 67–91.
16. de Leeuw E, Clavier C Breton E. Health policy–why research it and how: health political science. Health Res Policy Sys. 2014;12: 55.
17. Maggetti M, Trein P. Policy integration, problem–solving, and the coronavirus disease crisis: lessons for policy design. Policy and Society. 2022;41(1): 53–67.
18. Bernier NF, Clavier C. Public health policy research: making the case for a political science approach. Health Promotion International. 2011;26(1): 109–116.
19. Fafard P, de Leeuw E, Cassola A. Introduction: Virchow Revisited on the Importance of Public Health Political Science. In: Fafard P, Cassola A, de Leeuw E, (eds). Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Cham (Switzerland): Palgrave Macmillan. 2022. p. 3–14.
20. Barnish M, Tørnes M, Nelson–Horne B. How much evidence is there that political factors are related to population health outcomes? An internationally comparative systematic review. BMJ Open.2018;8: e020886.
21. Baum F, Townsend B, Fisher M, Browne–Yung K, Freeman T, Ziersch A, et al. Creating political will for action on health equity: practical lessons for public health policy actors. Int J Health Policy Manag. 2022;11(7): 947–960.
22. Cassola A, Fafard P, Palkovits M, Hoffman SJ. Mechanisms to Bridge the Gap Between Science and Politics in Evidence–Informed Policymaking: Mapping the Landscape. In: Fafard P, Cassola A, de Leeuw E, (eds). Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Cham (Switzerland): Palgrave Macmillan. 2022. p. 293–328.
23. Greer S. Professions, Data, and Political Will: From the Pandemic Toward a Political Science with Public Health. In: Fafard P, Cassola A, de Leeuw E, eds. Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Cham (Switzerland): Palgrave Macmillan. 2022. p. 33–57.
24. Holt DH, Frohlich KL. Moving Beyond Health in All Policies: Exploring How Policy Could Front and Centre the Reduction of Social Inequities in Health. In: Fafard P, Cassola A, de Leeuw E, eds. Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Cham (Switzerland): Palgrave Macmillan. 2022. p. 267–291.
25. Buse K, Tomson G, Kuruvilla S, Mahmood J, Alden A, van der Meulen M, et al. Tackling the politics of intersectoral action for the health of people and planet. BMJ. 2022;376: e068124.
26. Clavier C, Gagnon F, Poland B. Sidestepping the Stalemate: The Strategies of Public Health Actors for Circulating Evidence into the Policy Process. In: Fafard P, Cassola A, de Leeuw E, (eds). Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Cham (Switzerland): Palgrave Macmillan. 2022. p. 103–126.
27. de Leeuw, E. Is Local Better? Evolving Hybrid Theorising for Local Health Policies. In: Fafard P, Cassola A, de Leeuw E, (eds). Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Cham (Switzerland): Palgrave Macmillan. 2022. p. 153–185.
28. Bagenal J. A public health manifesto. The Lancet. 2022;399: 710–711.
29. Hunter EL. Politics and Public Health—Engaging the Third Rail. Journal of Public Health Management and Practice. 2016;22(5): 436–441.
30. Czabanowska K, Rethmeier KA, Lueddeke G, Smith T, Malho A, Otok R, Stankunas M. Public health in the 21^st century: working differently means leading and learning differently. Eur J Public Health. 2014;24(6): 1047–1052.
31. Löblová O. Epistemic communities and experts in health policy–making. European Journal of Public Health. 2018;28(suppl_3): 7–10.
32. Campos PA, Reich MR. Political Analysis for Health Policy Implementation. Health Syst Reform. 2019;5(3): 224–235.
33. Ho CJ, Khalid H, Skead K, Wong J. The politics of universal health coverage. Lancet 2022;399(10340): 2066–2074.
34. Mandl Stangl J. Towards the Path of "Health in All Policies" in Germany: Proposal for a Policy Paper. J Qual Healthcare Eco. 2021;4(6): 000248.
35. de Leeuw E, Fafard P, Cassola A. Conclusion: The Added Value of Political Science in, of, and with Public Health. In: Fafard P, Cassola A, de Leeuw E, eds. Integrating Science and Politics for Public Health. Palgrave Studies in Public Health Policy Research. Cham (Switzerland): Palgrave Macmillan. 2022. p. 329–339.
36. Shiffman J, Shawar Y. Framing and the formation of global health priorities. Lancet. 2022;399: 1977–1990.
37. O'Mara RJ, Hsu SI, Wilson DR. Should MD–PhD programs encourage graduate training in disciplines beyond conventional biomedical or clinical sciences? Acad Med. 2015;90(2): 161–164.
38. Vargas Velásquez A. Notas sobre el estado y las políticas públicas [Notes on state and public policy]. Santa Fe de Bogotá (Colombia): Almudena Editores. 1999.
39. Baum F, Townsend B, Fisher M, Browne–Yung K, Freeman T, Ziersch A, et al. Creating political will for action on health equity: practical lessons for public health policy actors. Int J Health Policy Manag. 2022;11(7): 947–960.
40. Macaulay B, Reinap M, Wilson MG, Kuchenmüller T. Integrating citizen engagement into evidence–informed health policy–making in eastern Europe and central Asia: scoping study and future research priorities. Health Res Policy Syst. 2022;20(1): 11.
41. Campbell C. Social capital, social movements and global public health: Fighting for health–enabling contexts in marginalised settings. Social Science & Medicine 2020;257: 112153.
42. Mandl Stangl J. The Importance of Community Social Capital in Building Sustainable and Resilient Health Systems. J Qual Healthcare Eco. 2022;5(6): 000306.