Post on 14-Jan-2016
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Developing integrated approaches in Impact Assessment – NRW perspectives
Institute for Health and Work North Rhine-Westphalia, LIGA.NRWWHO Collaborating Center for Regional Health Policy & Public Health
rainer.fehr@liga.nrw.de
XIth HIA conf, Granada, 14-15 April 2011
HIA Conf, Granada, April 2011 [11-17] Slide 2
State of NRW: Pop 17.8 mill
LIGA.NRW, incl. Department of Prevention and Innovation; legal basis: Public Health Service Act NRW
WHO Collaborating Center for Regional (i.e. subnational) Health Policy and Public Health
LIGA.NRW Overall goal: Promoting health, reducing BoD
Mission in practice: to inform policy-making at regional (subnational) and local level, with NRW = constituency
HIA Conf, Granada, April 2011 [11-17] Slide 3
State of NRW: Pop 17.8 mill, BoD p.a.~ 2.2 mill DALYs
LIGA.NRW, incl. Department of Prevention and Innovation; legal basis: Public Health Service Act NRW
WHO Collaborating Center for Regional (i.e. subnational) Health Policy and Public Health
LIGA.NRW Overall goal: Promoting health, reducing BoD
Mission in practice: to inform policy-making at regional (subnational) and local level, with NRW = constituency
HIA Conf, Granada, April 2011 [11-17] Slide 4
„Regional health policy“ Work examples H-I-A: „What is in the term?“ Selected avenidas for integration Conclusions
Topics
HIA Conf, Granada, April 2011 [11-17] Slide 5
Supporting and informing (local, regional) health policy-makers, health departments, health conferences
Supporting the preparation, implementation, evaluation of (local, regional) health targets
Providing basic information on health status (BoD) / H det‘s / H conseq‘s
Analysing trends, gaps; forecasting Estimating H needs, prevention potentials, policy
impacts Evaluations
„Regional health policy“ work examples
HIA Conf, Granada, April 2011 [11-17] Slide 6
Topics (LIGA.NRW): Drinking water privatization (Bull. WHO) European Employment Strategy (EES) (EPHIA project) Regional Land Use Planning in the Ruhr area NRW Housing Subsidy Program / Wohnraumförderungs-
programm (RAPID project) (cf. HIA Granada conf.)
Policy HIA (partial) examples
HIA Conf, Granada, April 2011 [11-17] Slide 7
An insight gained from Regional health policy work:
For different target groups, HIA is not necessarily the concept of interest. Instead:
For society: Health is the issue For policy-making: Health impact is (or may be) the issue For expert community: How to estimate the health impact is
the issue (HIA)
„Health is the issue“
HIA Conf, Granada, April 2011 [11-17] Slide 8
In this multi-layered HIA context, we need to consider „integration” for several reasons, incl.
(professional) credibility (practical) feasibility (intellectual) parsimony (monetary) efficiency ...
However, drawbacks of (and obstacles to) integration also need to be considered
One approach to systematically explore avenues to integration in HIA context: „Semantic triangle“, aka „What is in the term?“
„Integration“
HIA Conf, Granada, April 2011 [11-17] Slide 9
H-I-A: Systematic approach„What is in the term?“
HIA
HIA Conf, Granada, April 2011 [11-17] Slide 10
H-I-A: elementary components
H
HIAI A
HIA Conf, Granada, April 2011 [11-17] Slide 11
H-I-A: „Semantic triangle“
HI H HA
HIAI IA A
HIA Conf, Granada, April 2011 [11-17] Slide 12
H-I-A: „Semantic triangle“
HI H HA
HIAI IA A
HIA Conf, Granada, April 2011 [11-17] Slide 13
Health impact: Impact on health:
range of health determinants: physical and socio-economic environment, behavioral, etc.
need to integrate into „unified“ approach for health impact quantification: vision of a synthesis of DYNAMO HIA
and INTARESE/HEIMTSA approach
Impact of health: on health (care) system = HSIA HI may be the key interest in other sectors, e.g. education,
employment
-> challenge to try and be (more) „complete“ conc. HI
Integr‘ avenue I: „Health impact“
HIA Conf, Granada, April 2011 [11-17] Slide 14
Selected EC co-funded HIA projects: PHASE EPHIA HIA-NMAC INTARESE / HEIMTSA DYNAMO-HIA RAPID EU SF ...
Approach via cross-project integration
HIA Conf, Granada, April 2011 [11-17] Slide 15
Selected EC co-funded HIA projects: PHASE [Healthy Cities etc.] EPHIA [incl. EU policy HIA guide] HIA-NMAC [incl. range of HIA examples] INTARESE / HEIMTSA „Flagship“ projects DYNAMO-HIA of HI quantification RAPID [Risk Assessment „2.0“] EU SF [Structural Funds] ...
Approach via cross-project integration
}
HIA Conf, Granada, April 2011 [11-17] Slide 16
Selected EC co-funded HIA projects: PHASE [Healthy Cities etc.] EPHIA [EU policy HIA guide] HIA-NMAC [incl. sample HIAs] INTARESE / HEIMTSA „Flagship“ projects DYNAMO-HIA of HI quantification RAPID [Risk Assessment 2.0] EU SF [Structural Funds] ...
-> Do we exploit our R&D projects on HIA adequately?
Do we integrate the results into HIA practice?
Approach via Cross-project integration
}
HIA Conf, Granada, April 2011 [11-17] Slide 17
Range of models in existence (PREVENT, ICT, MicMac...) Potentially relevant for HIA Tradition of being developed separately, with interaction
limited or absent Vision: towards cross-model debate / possibly cross-
model integration
Approach via health impact quantification
HIA Conf, Granada, April 2011 [11-17] Slide 18
HIQ workshops: Düsseldorf 2010 – Invitational expert workshop (report) Granada 2011 – Pre-conference composite workshop
HIA Conf, Granada, April 2011 [11-17] Slide 19
Selected results: HIQ models could help to reach a new and improved quality
of science-policy interaction But: may give an unwarranted patina of robust science HI modeling exists in both the Environmental Health arena
and the general Public Health arena. Up to now, there is little cross-project debate; and mostly separated along this divide
So far, little evidence exists concerning: the demand of HIQ expressed by decision-makers on the satisfaction of these groups with HIQ results provided to them and on the eventual usefulness of the approach
1st HIQ workshop, Düsseldorf 2010
HIA Conf, Granada, April 2011 [11-17] Slide 20
Composite workshop: 2 „technical“ sessions (c. 25 partic. each), afternoon „debating“ session (c. 50 partic.)
Objective: exchanging information; promoting discussion Key HIQ questions: Why? For whom? What to quantify?
How? What scale level? etc. HEIMTSA/INTARESE, DYNAMO HIA = current „flagship
projects“; other proj‘s & models also relevant; e.g. RAPID, producing new insights
Users of HI quantifications: policy-makers, persons working in policy-making environments, citizens, health professionals incl. researchers, health administrators
HIA/HIQ appreciation in policy arena: depends on multiple factors, existing examples how interest can grow
„Health policy literacy“ = a (major) challenge---
>
2nd HIQ workshop, Granada, 13 April 2011
HIA Conf, Granada, April 2011 [11-17] Slide 21
Technical HIQ questions incl. data availiability; reliability; un-certainty; results presentation
Too early to evaluate HIQ, but HIQ widely seen as adding value to HIA
Next steps: to compile, and review, a set of practical examples of HIQ; and explore in detail how HIQ fits into the overall HIA
Since the „real“ goal is increasing health: possibly the process of HIQ turns out to be just as important as the numerical results.
2nd HIQ workshop, ctd.
HIA Conf, Granada, April 2011 [11-17] Slide 22
H-I-A: „Semantic triangle“
HI H HA
HIAI IA A
HIA Conf, Granada, April 2011 [11-17] Slide 23
Multitude of health assessments, incl. Health status, (indicator-based) health reporting Health trends, forecasts Health needs, prevention potentials HIA (prospective, ex ante) Health Technology Assessment Cost-benefit Evaluation ...Approach: To develop HIA as one health assessment among
others, identifying its specific position and interrelations[Work in progress]
(Integr‘ avenue II: „Health assessments“)
HIA Conf, Granada, April 2011 [11-17] Slide 24
H-I-A: „Semantic triangle“
HI H HA
HIAI IA A
HIA Conf, Granada, April 2011 [11-17] Slide 25
Internationally, a host of Impact Assessments (IAs) emerged, many of them at least partially related to human health
An initiative was started in 2009 to scientifically and practically deal with this “family“ of IAs, especially in order to harness the potential mutual benefits and to avoid the pitfall of unwel-come interference between them
Discussions: HIA09, Rotterdam (NL), with “World cafe” workshop EUPHA 2009, Lodz (PL) German Epidemiologic Association (DG Epi) 2010, Charité
Berlin (DE)
Integr‘ avenue III: „Family“ of h‘-related IAs
HIA Conf, Granada, April 2011 [11-17] Slide 26
H in SEA guidelines Wealth of SEA guidelines: 41 guideline doc‘s, 12 online
guidance webpages Health mentioned in almost all the guidelines Only few guidelines indicate how to assess health; whom to
consult with; when to include health experts Guidelines related to EU SEA directive: focussing on
biophysical det‘s, not socio-economic det‘s of health
J. Nowacki et al. (2011): Health in SEA guidelines. HIA Conf. Granada, 14-15 April 2011
Example of „family“ approach
HIA Conf, Granada, April 2011 [11-17] Slide 27
Family of health-related Impact AssessmentsRainer Fehr 1, Marco Martuzzi 2, Gabriel Gulis 3
1 NRW Institute of Health and Work (LIGA.NRW), Düsseldorf/Bielefeld (D) / WHO Collaborating Center for Regional Health Policy and Public Health, Bielefeld (DE),2 WHO European Center for Environment & Health, Rome (I), 3 University of Southern Denmark (USD), Esbjerg (DK)
Correspondence:Landesinstitut für Gesundheit und Arbeitdes Landes Nordrhein-Westfalen (LIGA.NRW)Ulenbergstraße 127-13140225 Düsseldorf
Contact: Rainer Fehr, Prof. Dr.med., MPH, Ph.D.Tel.: +49 521 8007 253Fax: +49 521 8007 299
Email: rainer.fehr@liga.nrw.de [10-70]
The authors wish to thank Laura Nölke for her technical support to the „Family“ initiative.
Links/ references: available from the authorsPrelim recommendations• Continue the exchange of information, and the joint discussion, within the “family”• In HIA publications (cf. books currently being prepared; gateways / websites), include chapters on other (health-related) IAs• Establish ongoing discussion on “family” within emerging HIA development efforts in professional associations, e.g. EUPHA.
Results / Conclusions: Selected results obtained in this initiative are shown in Boxes 1 & 2. Conclusions include the following:• Although the list of IAs for which names have been coined is long (and growing), a smaller number of IAs is supported by specific “cultures“, e.g. legal basis, political support, legacy of experience, material infrastructure, etc. (A range of rather specific IAs, e.g. Mental Well-being IA and Environmental Health IA was not included here but could provide additional insights.)• Each of the major IAs has features potentially inspiring for the further development of HIA; so it is clearly beneficial to look at the “IA family“ from this perspective• In contrast, avoiding mutual interference of IAs and the related issue of integrated IAs seem ratherhard to come by. All suggestions are welcome.
Context, objectives: Internationally, a host of Impact Assessments (IAs) has emerged, many of them at least partially related to human health. In order to harness the potential mutual benefits and to avoid the pitfall of unwelcome interference between them, an initiative was started in 2009 to scientifically and practically deal with this “family“ of IAs.
Box 2: Selected options for “integration“, incl. respective pro’s and con’sOption A: No integration, Pro: Requires no “extra” effort; strengths of existing IAs are maintained. Con: Risk of duplication of efforts; risk of confusing stakeholders; risk of producing contradictory input into decision-making and other policy contexts which could then contribute to “IA fatigue”.
Option B: “Partial” integration, e.g. where EIA or SEA is being performed, integrate “health” into it, Pro: Opportunity to involve stakeholders comprehensively and efficiently; results might be more easily communicated to decision-makers. Con: Difficult to establish “equal footing” of topics, disciplines.
Option C: “Full” integration, cf. EC “integrated approach”, Pro: Is “natural” approach since overall (not sectoral) impact is needed for policy-making; easiest to handle for stakeholders. Con: Requires all-round expertise; may be extremely demanding; alternatively, could fall way behind its potential. Existing IA cultures could go extinct without being adequately replaced.
Methods: The initiative involves colleagues from institutions with both experience in HIA and interest to carry the issue forward. Discussions were held at various occasions, including: HIA09, Rotterdam (NL), with “World cafe” workshop; EUPHA 2009, Lodz (PL); German Epidemiologic Association (DG Epi) 2010, Charité Berlin (DE).
A specialized version of IA dealing with (medical) technologies in health care; typically featuring strong infrastructure incl. dedicated (inter-)national institutions; standardized procedures; focus on “evidence” as assessed by systematic review, evaluation, and integration of scientific literature
1,790,000(Health Technology
Assessment)
(HTA)
Potential inspirations derivable for HIA
(for comparison: HIA = 814,000 hits in Yahoo®)
Yahoo®
hitsChoice of family
membersBox 1:
Acknowledging that policies may have unintended impacts on health systems, due to their large and complex structures; EC DG Health and Consumers‘ tool providing information about the objectives and health system functions that a proposal may impact on, either in a positive or negative way
641Health Systems IA
HSIA
Efforts to identify and analyse health-related (in)equality / (in)equity issues of new initiatives; high-ranking support, e.g. incorporated in the Jakarta Declaration (1997) and called for by the United Kingdom'sIndependent Inquiry into Inequalities in Health (1998)
11,300Health (In)Equalities IA
HEIA, HIIA
Standardized, wide-ranging and ambitious IA system for policy proposals within EC; strives to analyseboth benefits and costs; transparency: all IAs and all opinions of the IA Board on their quality are published online
34,700 Integrated IAIIA
EU Guide on Gender Impact Assessment: objective is to compare and assess, according to genderrelevant criteria, the current situation and trend with the expected development resulting from the introduction of the proposed policy
49,700 Gender IAGIA
Environmental sustainability refers to the ability of the functions of the environment to sustain the human ways of life. Socio-cultural sustainability: objective is to secure people’s socio-cultural and spiritual needsin an equitable way, with stability in human morality, relationships, and institutions
94,700 Sustainability IASIA (2)
Broad view of social determinants; Interorganizational Committee on Guidelines and Principles for SIA: „all social and cultural consequences ... of any public or private actions that alter the ways in which people live, work, play, relate to one another, organize to meet their needs, and generally cope ...“
651,000 Social IASIA (1)
> Europe-wide spread; legal basis, EC directives; “upstream” orientation (“causes of causes” / policy-related decision-making instead of project-related decision-making; range of impacts incl. secondary, cumulative, synergetic, short- and long-term, permanent or transient, positive and negative
1,200,000StrategicEnvironmentalAssessment
SEA
Worldwide spread; legal basis, EC directives; systematic procedures to identify, describe and assess impacts; established routines; community of practitioners; strives to consider interaction between factors, and to establish post-decision monitoring activities
6,210,000 Environmental IA
EIA
HIA09 Rotterdam:IA Family visiting World Cafe
Family members
Yahoo® hits
EIA 6,210,000
SEA 1,200,000
Soc IA 651,000
Sust IA 94,700
Gender IA 49,700
IIA 34,700
H (In)Equity IA 11,300
HSIA 641
(HTA) 1,790,000
Other strand of „family“ approach
HIA Conf, Granada, April 2011 [11-17] Slide 28
Option A: No integration, Pro: Requires no “extra” effort; strengths of existing IAs are maintained. Con: Risk of duplication of efforts; risk of confusing stakeholders; risk of producing contradictory input into decision-making and other policy contexts which could then contribute to “IA fatigue”
Option B: “Partial” integration, e.g. where EIA or SEA is being performed, integrate “health” into it, Pro: Opportunity to involve stakeholders comprehensively and efficiently; results might be more easily communicated to decision-makers. Con: Difficult to establish “equal footing” of topics, disciplines
Option C: “Full” integration, cf. EC “integrated approach”, Pro: Is “natural” approach since overall (not sectoral) impact is needed for policy-making; easiest to handle for stakeholders. Con: Requires all-round expertise; may be extremely demanding; alternatively, could fall way behind its potential. Existing IA cultures could go extinct without being adequately replaced
Crude typology for „integration“
HIA Conf, Granada, April 2011 [11-17] Slide 29
Although the list of IAs for which names have been coined is long (and growing), a smaller number of IAs is supported by specific “cultures“, e.g. political support; legacy of experience
Each of the major IAs has features potentially inspiring for the further development of HIA
Recommendations: Continue exchange of information within the “family” In HIA information hubs (cf. books currently being prepared;
gate-ways), include chapters on various (health-related) IAs Establish ongoing discussion on “family” within emerging HIA
development efforts in professional associations, e.g. EUPHA
Conclusions / Rec‘s on „Family“
HIA Conf, Granada, April 2011 [11-17] Slide 30
Concerning HIA, „health“ is the issue for society; „health impact“for policy-making; HIA for the PH community
Multitude of „integrative avenidas“ can be derived, e.g., from H-I-A semantic triangle, incl. „HI“, „HAs“, „IAs“
Several integrative approaches are readily available, e.g. „Family of IAs“
Seems indispensable to „think“ integration, to be aware of the contexts, especially: complexity of HI; range of HAs other than HIA; IA cultures beyond HIA
Neither always feasible nor desirable to „do“ integration; needs critical debate and evaluation
Overall conclusions
HIA Conf, Granada, April 2011 [11-17] Slide 31
From (Regional) Health Policy perspective: HIA = a strategic topic, deserving ongoing attention, exchange of information, critical discussion
If EC and WHO integrate HIA (+/- systematically and compre-hensively) to their own policy-making, e.g. emerging „Health 2020“ program -> strong signal for HIA
„Integration“ a candidate topic for future HIA conferences and HIQ workshops
Lookout