UNSW research centre for primary health care and equity

developing integrated approaches in impact assessment: challenges for health equity

Associate Professor Marilyn Wise

Centre for Health Equity Training Research and Evaluation (CHETRE)

what is the logic pathway?

• healthy population

• health equity

• equitable distribution of the determinants of health – socially just, healthy society

• public policy – that creates equal opportunities (at least) for access to the determinants of health – the goods/advantages arising from social cooperation

UNSW Research Centre for Primary Health Care & Equity

UNSW Research Centre for Primary Health Care & Equity

which are

– education property– employment child care– income child welfare benefits– housing honours and prizes– transport leisure opportunities– health care (Miller 1999)

– food security recognition– security/safety respect – peace (Fraser)

(Marmot, Wilkinson)

UNSW Research Centre for Primary Health Care & Equity

paradoxically

some background evidence

• Szreter’s work demonstrated the relationship between enfranchisement and the earliest purposeful public health successes

• it is worthy of consideration, too, that the living conditions that were the focus of these early efforts were shared by most members of the populations of the newly industrialising nations

UNSW Research Centre for Primary Health Care & Equity

• evidence and knowledge are necessary but not sufficient to bring about changes – in organisations and/or in individuals’ and communities’ behaviours

• a recent reflection on evidence of the influence of convincing scientific evidence on public policy re addictions concluded that:– the more the issue is at the regulatory or population level, the less

likely is science to influence policy;– the closer the issue gets to the individual and a targeted approach,

the more science is likely to have a commanding influence.

Anderson P, Room R. Addictions and European policy: has the European Project stifled science-led policy? Editorial. Drug and Alcohol Review 2011; 30: 117-8.

UNSW Research Centre for Primary Health Care & Equity

and

• working across disciplines and sectors to bring about policy change to achieve mutually agreed goals has proven to be challenging for the health sector

• engaging with communities has been framed as ‘empowering’ and/or as necessary to understand needs/solutions – or as ‘self-determination’ – a ‘bottom up’ approach that seems to ignore or deny the role of ‘the top’

UNSW Research Centre for Primary Health Care & Equity

IIA offers the possibility of changes to policy making and policy content necessary to cope with interdependent, complex problems

• increasing the capacity to describe and measure the relationships among the multiple determinants of health and health outcomes - IIA offering an expanded scientific and technical evidence base – what to do!

• increasing understanding across disciplines and sectors of the relationships between individual sectoral decisions and population health – IIA as a structured conversation about shared responsibilities and shared benefits – who decides, who does the work?

UNSW Research Centre for Primary Health Care & Equity

IIA offers opportunities for

• increasing the likelihood of developing policy solutions that are implementable and implemented by multiple sectors

• which is interesting given the rationale often offered for community participation – because they will ‘own’ the decisions and hence, be more likely to act upon them

UNSW Research Centre for Primary Health Care & Equity

the rationale for Integrated Impact Assessment

– more effective – drawing together a wider range of stakeholders to decide on ‘problem/determinants/solutions’ – creating shared meaning, particularly about complex problems in which sectors and disciplines are interdependent

– more effective – addressing potentially conflicting goals and recommendations; reducing duplication; recognising shared goals and responses – facilitating negotiation and shared benefits

– more effective – expanded methods for measurement, assessment and prediction

– more efficient than ‘single’ issue impact assessments

UNSW Research Centre for Primary Health Care & Equity

but there are challenges

• complexity and integration can mean that health is defined narrowly or ‘goes missing’

• technical and scientific demands very great – creating another form of ‘expert’ driven policy-making

• complicated to draw together experts and policy

officers from multiple sectors and resources are necessary to establish and maintain the relationships

• may reduce civil society’s ability to participate – – definitions of health; priorities; solutions; health; trust

UNSW Research Centre for Primary Health Care & Equity

and it may be no more likely to be conducted

• institutionalisation – no single policy sector home – where would it be institutionalised?

• trigger– no single policy sector has the ‘logical’ mandate to trigger an IIA in

every case and some evidence that the trigger is most often a very large project or plan

• mandated– narrow definitions of health– and, beyond EA, little evidence of increase in routine conduct

• capacity– training a skilled workforce complicated– resources – financial, technical, human

UNSW Research Centre for Primary Health Care & Equity

what makes the conduct of IA re sustainable development more likely?

• relevance – in principle agreement with the idea but more convincing indicators needed, particularly social indicators

• accuracy – quantitative considered to be reliable, precise, useful; unwilling to rely on data collected using qualitative methods or from other than widely recognised, reputable sources

• legitimacy – agreement among stakeholders re the concepts and principles for conduct, and on responsibilities for implementation

UNSW Research Centre for Primary Health Care & Equity

what will enhance uptake of recommendations of an IIA

on sustainability?

• structured conversation among stakeholders throughout

• agreement that IA meets scientific standards, is produced by a fair process that reflects the interests of stakeholders, and is salient to potential users.

De Smedt P. Impact Assessment practice to support sustainable policy objectives in Europe. 18 th World IMACS/MODSIM Congress, Cairns, Australia, 2009.

UNSW Research Centre for Primary Health Care & Equity

what has gone missing from this analysis?

UNSW Research Centre for Primary Health Care & Equity

inequity

UNSW Research Centre for Primary Health Care & Equity

UNSW Research Centre for Primary Health Care & Equity

is that important?

• the greatest access to the positive social goods and advantages clusters around the same population groups and locations; the most limited access clusters around the same population groups and locations – no matter what the issue;

• the gap in life expectancy between those in the most advantaged group and ‘the rest’ appears to be growing –

losing ground or holding pattern?

• inequality experienced by some, specific groups – systematically, persistently, routinely – inequity

consideration of health equity is not inherent in IIA

– nor can IIA be the vehicle through which to build the civil society;

– but without inclusion in the policy-formation process, including IIA, for example, we are failing to recognise the direct, positive effects that inclusion has on health as well as being essential to identifying priority issues, their determinants and solutions, and to legitimising these

– it is also the case that it is the most marginalised groups who are experiencing (or are likely to experience), early, the negative consequences of the ‘complex’ problems such as climate change… the canary in the mine alerting but may also point to effective solutions

UNSW Research Centre for Primary Health Care & Equity

what will enhance the development and uptake of recommendations to increase equity?

• technical development – enhancing the power of ‘evidence’ to describe problems, their causes/determinants, and solutions – define equity and health equity – specific to each case– differentiate between inequality and inequity– include explicit attention to equity in each step of the impact

assessment

UNSW Research Centre for Primary Health Care & Equity

• process development – enhancing the power of impact assessment as a structured conversation to create shared meaning – specific inclusion of marginalised communities through civil society

organisations (where possible) with a representative mandate– specific engagement of stakeholders wherever possible– greater emphasis on deliberative processes through which to

conduct the ‘structured conversation’– dignity and respect are critical; personal relationships count

UNSW Research Centre for Primary Health Care & Equity

IIA does have the potential to contribute to health and health equity

UNSW Research Centre for Primary Health Care & Equity

• to achieve policy change across multiple sectors but there is no substitute for political engagement

– from the beginning of organised public health action, all changes in public policy have had to be fought for over long periods;

– IIA offers the opportunity to provide more focused, evidence-based information to support advocacy

– it also offers the opportunity to increase the extent of cross sectoral engagement in policy making –

– and to increase civil society engagement in policy making

and learn from history

• it offers more but only if it is conducted

• sustainability may be the universal stimulus to change in the 21st century – the equivalent of the industrial revolution in the 18th and 19th centuries

• IIA may prove to be the only logical form of impact assessment to address the integrated systems that are responsible for ‘creating’ the problems

• and it must be joined to activism and political power.

UNSW Research Centre for Primary Health Care & Equity