Erice, Italy14 April 2012

Sarah SimpsonEquiACTConjoint Lecturer, UNSW

Equity Audit: non-health interventions

Health equity audit – UK model

Source: Goodrich & Pottle, 2005

Health impact assessment

1. Screening2. Scoping3. Identification of impacts & collection of

data4. Assessment5. Final report and recommendations6. Monitoring and evaluation

Health Equity Audit

1. Agree partners and issues

2. Equity profile – identify the gap

3. Agree high impact action to narrow the gap

4. Agree priorities for action

5. Secure changes in investment and service delivery

6. Review progress and assess impact

Health Impact Assessment

1. Screening2. Scoping3. Identification of

impacts & collection of data

4. Assessment5. Final report and

recommendations6. Monitoring and

evaluation

HEA and HIA: related & slightly different

Health Lens Analysis: South Australia1. Engage - establishing and maintaining strong

collaborative relationships with other sectors.2. Gather evidence - establishing impacts

between health and the policy area under focus, and identifying evidence-based solutions or policy options.

3. Generate - producing a set of policy recommendations and a final report.

4. Navigate - helping to steer the recommendations through the decision-making process.

5. Evaluate - determining the effectiveness of the HLA.

Source: Wiliams, 2010.

Critical issues

1. What is the issue & why is it important? 2. Scoping the assessment

– What is the relationship between the determinant and health & inequalities: mapping pathways – conceptual framework.

– What data to collect & how?– Defining “success”

3. A systematic process for analysis of the knowledge/data collected

4. Making recommendations5. Making the case for uptake

• Treasury• National Statistical

Institute• Agriculture and

Forestry• Communications• Cultural Assets and

Activities• Defence• Foreign Affairs

• Interior• Justice• Labor and Social

Provision• Public Education• Infrastructure and

Transport• Customs and excise

Non-health interventions: scope – Italian context

Non-health interventions: why equity audit?• What is the issue?

Improved health of workers, improved employment conditions, better productivity for employers …?

• Who is interested?Health or the other sectorsWho’s driving the discussion and asking for an equity audit?What’s in it for other sectors? Mutual benefit?

• What is at stake?

Non-health interventions: why HEA?

What is the incentive/motivation for HEA?1. Health sector is at the core of the

exercise – health sector interest?2. Win-win or mutual interest?3. What health can do for other sectors?4. Damage limitation in relation to negative

health impacts?

First step of Health Lens Analysis: engage

Source: Wiliams, 2010.

Engaging in a Health Lens Analysis

• Develop the relationship• Identify/clarify contextual issues• Negotiate and agree on policy focus• Form team and identify resources• Plan work and determine process• Establish evaluation criteria

(Source: Government of South Australia, 2010)

Worked example: labor market reform in Italy

Labor market reform should aim to lower labor adjustments costs, introduce more

flexibility at the core, increase participation, especially among women, and improve

activation policies.

(Source: IMF, 2012; p.5)

Labor market reform in Italy

April 2012 draft law sought to : • Tackle job insecurity & dualism• Make employment protection &

unemployment insurance more even toEncourage more stable employment relationshipsLower firing costsIncrease employment & participation, especially of youth

• Strengthen active labor market policies(Source: IMF., 2012; p.11)

Non-health interventions: scoping the audit• What is the relationship between the social

determinant and health and equity?• Is there much evidence/data? And of

what?at the aggregate level?or beyond thiswho collects and who owns the datawho is doing work on these issues e.g. which academics and institutions?

From employment to health?

From employment to health inequalities?

Connecting employment & health inequalities

Source: EMCONET Final report, 2007; p.31

SDH

Quality of employme

nt & distribution of health outcomes

Definitions – employment issues

1. Employment relations – relationship between an employer that hires workers and an employee who contributes labour, usually in return for payment or wages - Power relations & level of social protection

2. Employment conditions – 5 dimensions – unemployment, precarious employment, informal employment & informal jobs, child labour, and slavery/bonded labour

3. Working conditions - tasks performed by the workers, way work is organised, physical & psychosocial work environment & technology used

Source: EMCONET Final report, 2007.

Worked example - labor market reform in Italy: the issues (1)• For a 15–24 year-old, the chance of being

in education is about 60 percent and being employed is slightly over 20 percent compared to over 35 percent in the euro area.

• For a 40–64 year-old, the chance of being employed is only 60 percent (mainly driven by low female employment) and being inactive about 35 percent (almost 50 percent if a woman).

(IMF. Italy. Selected Issues. 2012; pp.11-13)

Worked example - labor market reform in Italy: the issues (2)

• If employed, a 15–24 year-old would have a 50 percent chance that the contract would be open-ended, while for a 40–64 year-old this chance would be over 90 percent.

• The transition probability from unemployed to inactive is higher than in other countries, especially for women and in the South (Istat, 2011) while inactivity tends to be almost permanent.

(IMF. Italy. Selected Issues. 2012; pp.11-13)

Introducing an equity lens

Erice – equity lens

Equity lens – priority public health conditions

Source: Equity, Social Determinants and public health programmes. Blas E, Sivasanakurup A (eds). Geneva, WHO, 2010

Employment and health inequalities

• In links between employment and health – who gains?

• Do all groups have the same level of health improvement?

• Are some groups in the population doing better than others?

Type of work – office workers, manual laborers, sex workersFormal or informal sectorMen compared to womenYounger people compared to older peopleLow education/lower qualifications

Employment and health inequalities in Italy• Who gains? • Do all groups have the same level of

health improvement?• Are some groups in the population doing

better than others?Type of work –office workers, manual laborers, sex workers ….Formal or informal sectorMen compared to womenYounger people compared to older peopleLow education/lower qualificationsRoma, migrants ..

Age & life stage

• Pre-natal• Babies/infants• Young children• Adolescents• Pregnant women• Older people

Socioeconomic & other• Level of education

• Level of income• Ethnicity e.g. Roma• Citizenship status• Place of residence ….

“Vulnerable groups” and equity

Physiological & biological

Socially determined

Equity: concept of “success”

Reducing inequalities – what does this look like

1. Not making existing inequalities worse2. Remedying health disadvantage3. Closing the gap4. Tackling the social gradient

Tackling inequalities: what does it look like?

Source: Asquith et al,, 2011 ; p.39

Employment & equity: “decent work”1. Freedom from coercion2. Job security – contracts & safe

employment conditions3. Fair income – to guarantee adequate

livelihood to the needs of society4. Job protection & availability of social

benefits5. Respect & dignity at work6. Workplace participation7. Enrichment & lack of alienation

Source: ILO in EMCONET Final report, 2007

Employment conditions – health & inequalities

Source: EMCONET Final report, 2007; p.32

Employment conditionsWho is:

• In full employment?• Unemployed• Precariously employed• In informal

employment• Child labor ?• Slavery & bonded

labor?

Working conditionsWhat are the exposures

and risk factors for these groups?

• Physical – injuries• Chemicals & other

exposures• Ergonomic• Mental & psychosocial

Worked example: labor market in Italy

Where to for the data?

Where to for the existing available data• Key ministries/departments and

government agencies for the statistics e.g. National Statistics agency, education, employment, finance/treasury etc

• Specialist agencies within Italy e.g. CGL• International agencies e.g. OECD, ILO, IOM

Where to for the data: beyond numbers• But what of informal workers (particularly

working in industry/manual jobs and or undocumented migrants)

Do they appear in the formal numbers?Do the numbers reflect their reality?How to get beyond the numbers?In all cases – there is a need to go beyond the numbers in order to develop a comprehensive

equity profile to inform policy responses – qualitative research or knowledge collection

Beyond the numbers: options

• Surveys through NGOs or advocacy groups dealing with these issues

• Focus group interviews conducted by peer mediators with those working in the informal economy – e.g. undocumented migrants

• Stakeholder interviews with key academics, NGOs and advocacy organizations

Worked example: continued

Engagement & scoping - in Italy• What are the key policy issues in relation

to employment conditions and health inequalities?

• Who are the stakeholders? Which agencies – government, academic, NGOs & civil society?

• Which government agency is or needs to be leading the process to ensure uptake of these issues?

• What will be counted as “evidence”?

Purpose of an equity audit

• Purpose of an equity audit is to develop knowledge about potential health equity impacts to inform decision making – for planning, for implementation, for monitoring …. depending on the cycle of the policy/intervention process

Great expectations?

• Equity audit report is done – what is the expected outcome?

• Outcomes can be variedBetter information for evidence-informed implementation and or monitoringUptake of some or all of the recommendations into the policy, or planning processesA report that sits on the shelf as evidence of potential impacts?

“Making the case”

• Think about framing of the messages – who is your audience• Language• Engagement • Context

• Prioritising recommendations and health equity impacts – not an infinite list

• Solution oriented – improvement and amelioration not resistance/impasse – positive policy and intervention development

Take home messages

• Equity audit reflects similar steps to other assessment processes e.g. HIA, planning, health lens analysis

• Action on social determinants of health is not the same thing as action on inequalities

• Vulnerability - interaction between physiological and socioeconomic

• Getting the engagement and scoping right• Agreed conceptual mapping • Going beyond the numbers• Making the case for uptake – moving the audit off

the desk!

THANK YOU

References• Asquith H, Shaffelburg S, Adepoju A, Griffiths P. Health inequalities

commissioning framework. NHS Kensington and Chelsea, January 2011. Available from http://www.instituteofhealthequity.org/projects/health-inequalities-commissioning-framework-

• Employment Conditions Knowledge Network (EMCONET). Final Report, 20 September 2007. Available from http://www.who.int/social_determinants/resources/articles/emconet_who_report.pdf

• Goodrich J, Pottle M. Making the case: health equity audit [Internet]. NHS Health Development Agency; 2005 [cited 2013 Jan 29]. Available from: http://www.nice.org.uk/nicemedia/docs/Making%20the%20case-13-03.pdf

• Government of South Australia, SA Health. Health in All Policies: The South Australian Approach. Government of South Australia; 2010.

• International Monetary Fund. Italy. Selected Issues [Internet]. Washington D.C: International Monetary Fund; 2012 Jul. Report No.: 12/168. Available from: http://www.imf.org/external/pubs/ft/scr/2012/cr12168.pdf

• Equity, Social Determinants and public health programmes. Blas E, Sivasanakurup A (eds). Geneva, WHO, 2010

• Williams C. South Australia’s Health in All Policies Approach. Adelaide; 2010.

Useful sites/resources

• EMCONET - http://www.emconet.org • HIA gateway -

http://www.apho.org.uk/default.aspx?QN=P_HIA

• OECD - http://stats.oecd.org and http://www.oecd.org/employment/emp/onlineoecdemploymentdatabase.htm

• ILO - http://www.ilo.org/global/lang--en/index.htm

• WHO - http://www.who.int/social_determinants/themes/en/