developing integrated approaches in impact assessment

Developing integrated approaches in Impact Assessment – NRW perspectives

Institute of Health and Work North Rhine-Westphalia, LIGA.NRWWHO Collaborating Center for Regional Health Policy & Public Health

[email protected] [11-17]

XIth HIA conf, Granada, 14-15 April 2011

HIA Conf, Granada, April 2011 rf [11-17] Slide 1

State of NRW: Pop 17.8 mill, BoD p.a.~ 2.2 mill DALYsLIGA.NRW, incl. Department of Prevention and Innovation;

legal basis: Public Health Service Act NRWWHO Collaborating Center for Regional (i.e. subnational)

Health Policy and Public Health

LIGA.NRW Overall goal: Promoting health, reducing BoDMission in practice: to inform policy-making at regional

(subnational) and local level, with NRW = constituency


� „Regional health policy“ Work examples� H-I-A: „What is in the term?“� Selected avenidas for integration� Conclusions

Topics


� 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


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. presentation Odile Mekel et al. at HIA Granada conf.)

Policy HIA (partial) examples


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“


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 needto be considered

One approach to systematically explore avenues to integrationin HIA context: „Semantic triangle“, aka „What is in the term?“

„Integration“


H-I-A: „Semantic triangle“

AIAIHIA

HAHHI


Health impact:� Impact on health:

� range of health determinants: physical and socio-economicenvironment, 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“


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

}


� 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


HIQ workshops:� Düsseldorf 2010 –Invitational expertworkshop (report)� Granada 2011 –Pre-conferencecomposite workshop


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


� 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 workingin policy-making environments, citizens, health professionalsincl. 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


Technical HIQ questions incl. data availiability; reliability; un-certainty; results presentation

Too early to evaluate HIQ, but HIQ widely seen as adding valueto HIA

Next steps: to compile, and review, a set of practical examplesof HIQ; and explore in detail how HIQ fits into the overall HIA

Since the „real“ goal is increasing health: possibly the processof HIQ turns out to be just as important as the numericalresults.

2nd HIQ workshop, ctd.



AIAIHIA

HAHHI


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“



AIAIHIA

HAHHI


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 harnessthe 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


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


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 299Email: [email protected] [10-70]

The authors wish to thank Laura Nölke for her technical support to the „Family“ initiative.Links/ references: available from the authors

Prelim 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

1,790,000(HTA)

641HSIA

11,300H (In)Equity IA

34,700IIA

49,700Gender IA

94,700Sust IA

651,000Soc IA

1,200,000SEA

6,210,000EIA

Yahoo® hitsFamilymembers

Other strands of „family“ approach


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

Options towards „IIA“


� 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“


� Concerning HIA, „health“ is the issue for society; „healthimpact“for policy-making; HIA for the PH community

� Multitude of „integrative avenidas“ can be derived, e.g., fromH-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 otherthan HIA; IA cultures beyond HIA

� Neither always feasible nor desirable to „do“ integration; needs critical debate and evaluation

Overall conclusions


� From (Regional) Health Policy perspective: HIA = a strategictopic, 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 conferencesand HIQ workshops

Perspectives

developing integrated approaches in impact assessment

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