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Equity-focused health impact assessment: A tool to assist policy makers in addressing health inequalities
Environmental Impact Assessment Review 25 (2005) 772 – 782 www.elsevier.com/locate/eiar
Equity-focused health impact assessment: A tool to assist policy makers in addressing health inequalities Sarah Simpson a,*, Mary Mahoney b, Elizabeth Harris b, Rosemary Aldrich c, Jenny Stewart-Williams d a
Centre for Health Equity Training Research and Evaluation, School of Public Health and Community Medicine, University of NSW, Australia b Health Impact Assessment Research Unit, Faculty of Health and Behavioural Sciences, Deakin University, Victoria, Australia c University of Newcastle, NSW, Australia d Newcastle Institute of Public Health, University of Newcastle, NSW, Australia Available online 15 August 2005
Abstract In Australasia (Australia and New Zealand) the use of health impact assessment (HIA) as a tool for improved policy development is comparatively new. The public health workforce do not routinely assess the potential health and equity impacts of proposed policies or programs. The Australasian Collaboration for Health Equity Impact Assessment was funded to develop a strategic framework for equity-focused HIA (EFHIA) with the intent of strengthening the ways in which equity is addressed in each step of HIA. The collaboration developed a draft framework for EFHIA that mirrored, but modified the commonly accepted steps of HIA; tested the draft framework in six different health service delivery settings; analysed the feedback about application of the draft EFHIA framework and modified it accordingly. The strategic framework shows promise in providing a systematic process for identifying potential differential health impacts and assessing the extent to which these are avoidable and unfair. This paper presents the EFHIA framework and discusses some of the issues that arose in the case study sites undertaking equity-focused HIA. D 2005 Elsevier Inc. All rights reserved. Keywords: Health impact assessment; Equity
* Corresponding author. Tel.: +61 2 9385 0420; fax: +61 2 9385 0140. E-mail address: [email protected] (S. Simpson). 0195-9255/$ - see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.eiar.2005.07.010
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1. Introduction Australia and New Zealand have been international leaders in the development of health impact assessment (HIA) as part of environmental health frameworks. In these countries health impacts have traditionally been considered as part of environmental impact assessment (EIA) (Harris and Simpson, 2003b; Mahoney and Durham, 2002). Recently the two countries have become increasingly interested in exploring the use of HIA for policy development (National Public Health Partnership, 2003; Mahoney and Durham, 2002; Public Health Advisory Committee, 2004). However, the use of HIA as a tool for policy development is still comparatively new within public health, and public health workers do not routinely assess the potential health and equity impacts of proposed policies, programs or projects (hereafter referred to as proposals). Health impact assessment uses a structured, stepwise impact assessment process to assess the potential health impacts of proposed policies (for example a new taxation policy) (European Centre for Health Policy, 1999; Mahoney and Morgan, 2001). Other characteristics integral to this application of HIA include, ! use of a broad definition of health—to include assessments of hazards and risk as well as ways in which health could be promoted and the social forces that impact negatively on health reduced (Harris and Simpson, 2003b); ! assessment of the health impacts on populations directly and indirectly affected; ! assessment of the distribution of these impacts across different population groups (Simpson et al., 2004). Health impact assessment provides a structured process for improving a proposal by providing decision-makers with information on potential health impacts and recommendations for improving the proposal, thereby contributing to improved policy development. In addition, while equity is considered a core value of HIA (Ritsatakis et al., 2002; Douglas and Scott-Samuel, 2001; Douglas et al., 2001; European Centre for Health Policy, 1999; Health Development Agency, 2001; Kemm, 2001), it is also important to make explicit the consideration of equity, so that HIA can illuminate the equity impacts of a proposal. During the mid 1990s key commentators on HIA advocated its use to assess the potential equity impacts of proposals (particularly policy proposals)—this was referred to as health inequalities impact assessment (Acheson et al., 1998; Acheson, 2000; World Health Organisation, 1997). There have been some debate about the need for a yet another separate form of impact assessment. Some practitioners of HIA have indicated a preference for equity in every HIA rather than health inequalities impact assessment (Douglas and Scott-Samuel, 2001; Ritsatakis et al., 2002). There is agreement among practitioners that the role of HIA, as well as being population focused, is to identify any differential impacts that may arise for specific groups likely to be affected by the proposal (European Centre for Health Policy, 1999; Douglas et al., 2001; Kemm, 2001; Ritsatakis et al., 2002). Examples of tools and guidance that have been developed to facilitate an equity-focus within HIA and in public health practice include the Bro Taf Health Inequalities Impact Assessment tool (National Public Health Service for Wales, 2003; Welsh Health Impact Assessment Support Unit, 2004), the Equity Audit (Association of
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Public Health Observatories, 2003; Hamer et al., 2003) and the Equity Gauge (Global Equity Gauge Alliance, 2003; Ntuli et al., 2003). However experience of HIA in the Australasian context together with a review of the published literature and of practice of HIA in other contexts indicate that addressing equity in HIA is currently an aspiration rather than a reality (Harris-Roxas et al., 2004; Ritsatakis et al., 2002). Specific findings were that: ! equity is not effectively addressed in other forms of impact assessment and issues of avoidability and fairness are rarely examined; ! there is often an uncritical assumption that increased community participation will in itself ensure an equity perspective; ! there is a lack of structured guidance or tools to assist practitioners to ensure bequity in every HIAQ; ! assessment stops at identifying differential impacts and fails to move to determining avoidability, fairness and ways to address inequities (Harris-Roxas et al., 2004). This debate is not unique to HIA. It is occurring elsewhere in the impact assessment literature. Connelly and Richardson (2005) recently questioned the assumption that the process of deliberation in Strategic Environmental Assessments (SEA) would result in sustainable and equitable outcomes for all. They advocated the use of environmental justice as a structured process during SEA in order to make the different and hard tradeoffs explicit thereby giving some guidance on how sustainability might be achieved. Based on the belief that the consideration of equity needed to be made explicit in HIA, and encouraged by the growing interest in the broader application of HIA in Australasia, in 2002 a collaboration of three universities proposed the development of a strategic framework for health inequalities impact assessment. The partners in the collaboration were the Institute of Public Health at Newcastle University (NSW), Deakin University (Victoria) and the Centre for Health Equity Training Research and Evaluation at the University of New South Wales. The proposal was accepted and funded by the Australian Government Department of Health and Ageing (DOHA) and the framework was subsequently renamed equity-focused HIA (EFHIA). The intention in developing the framework was not to develop yet another form of HIA but to produce more explicit guidance for practitioners on how they could systematically address equity within the existing process of HIA. This paper will present the development of the EFHIA framework developed and discuss some of the issues that arose in case studies of its use.
2. Defining equity and equity-focused health impact assessment An equity approach recognises that not everyone has the same level of health or level of resources to deal with their health problems. It may therefore be important to deal with people differently in order to work towards equal outcomes, where: . . .the aim of policy for equity and health is. . .to reduce or eliminate those [health differences], which result from factors which are considered to be both avoidable and unfair (Whitehead, 1990).
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Equity-focused decisions are based on the values and assumptions of the decisionmakers. It is therefore important that these values and assumptions are made explicit and that it is recognised that there may be competing values and assumptions that will make the decision contested (Harris and Simpson, 2003a). Equity-focused HIA uses health impact assessment methodology in a structured way to explore the potential differential impacts of a proposal on the health of specific groups within a population and to assess if these differential impacts are inequitable. Equity-focused HIA: ! Identifies the distribution of health impacts across the population. ! Considers if the identified potential health impacts are shared unequally across the population (e.g. some groups may potentially be more adversely or more positively affected than others). ! Assesses whether these potential differential health impacts are avoidable and unfair— that is, inequitable. ! Reduces the potential for these differential impacts to become health inequities by using the findings from the EFHIA to amend, ameliorate and improve the proposed policy, program or project (ideally before it is implemented).
3. Development of the EFHIA framework The Australasian Collaboration for Health Equity Impact Assessment (ACHEIA) was formed to provide guidance to the EFHIA project. It included the six investigators; the project officer; international advisers from university and government sectors in the areas of equity, policy development, impact assessment and HIA; the case study partners from the EFHIA sites; organisational nominees (e.g. DOHA); and indigenous consultants from Australia and New Zealand. A full list of the members of ACHEIA is available from the project website (ACHEIA, 2005). The process for developing and testing of the EFHIA framework included: 1. Developing a draft framework for equity-focused HIA that adapted the commonly accepted steps of HIA—screening, scoping, identification and assessment/appraisal of impacts, negotiation, development of recommendations and evaluation (West Midlands Directors of Public Health Group, 2000; Scott-Samuel et al., 1998). 2. Developing a manual outlining the draft framework to assist the case study sites. 3. Testing the EFHIA framework in six case study sites in a range of health settings (listed in Table 1). An EFHIA was undertaken with guidance from one of the investigators at each of these sites, which offered a range of health settings. 4. Undertaking a systematic review of the literature to identify other models for incorporating equity considerations into HIA, and to determine the extent to which equity considerations were incorporated in reported HIAs (Harris-Roxas et al., 2004). 5. Holding a 2 day international capacity building meeting to showcase the draft EFHIA framework. This meeting included a 1 day training program on applying the framework.
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Table 1 The six EFHIA case study sites 1. New Zealand Ministry of Health. EFHIA of Health Eating Action. Policy, a policy which was written with specific reference to Maori health. 2. Royal Australasian College of Physicians. EFHIA of Support Scheme for Rural Specialists, a continuing education and professional development program for specialists in rural Australia using videoconferencing as a delivery mechanism. 3. National Health and Medical Research Council. EFHIA of a consumer brochure and booklet to accompany the councils Dietary Guidelines for Older Australians. The aim of the publications was to provide information about diet and nutrient intake to independent healthy older Australians. 4. John Hunter Hospital. EFHIA of existing outpatient Cardiac Rehabilitation Program, which aimed to optimize the recovery of patients following an acute cardiac event and to reduce the risk of further cardiac events. 5. Australian Capital Territory Health Promotion Board. EFHIA of the annual Community Funding Program of grants and/or sponsorships. 6. EFHIA of South Australian Breastfeeding Action Plan 2004–2006 where the EFHIA focused on assessing the major components of a plan to promote breastfeeding in families and community settings.
6. Analysing feedback from the sites and the workshop and using this analysis to modify the EFHIA framework.
4. The framework 4.1. Screening with an equity-focus The first step in EFHIA is screening in order to determine whether a HIA is actually required. The equity dimension of screening in EFHIA considers whether the potential health impacts are likely to be differentially distributed by factors such as socioeconomic status, ethnicity, gender, geography and if these differential impacts are bunfairQ and bavoidableQ—that is binequitableQ (Mahoney et al., 2004). Beginning with an equity-focus requires practitioners to look beyond the health impacts for the overall population to systematic health differences in sub-groups of the population and groups who are not specifically included in the proposal. This approach is not dissimilar to that proposed in the Bro Taf guidance and Welsh Guidance on HIA where a range of potentially bvulnerableQ population groups are identified for practitioners to consider during the screening step (Welsh Health Impact Assessment Support Unit, 2004; National Public Health Service for Wales, 2003; Fig. 1). Experience at the six case study sites during the screening step of EFHIA showed the importance of investing time in defining why an equity-focused HIA has been chosen and to develop a shared understanding of equity. It is also important that the equity-rationale be made explicit in the screening report. Some found it difficult to acknowledge that well-intentioned proposals could have unintended and unanticipated consequences that could be judged inequitable. There was a strong temptation to revise the proposal at the screening and scoping steps as potential equity impacts are identified.
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Determining the suitability of the policy or practice for an EFHIA and the feasibility of undertaking it. This step includes consideration of: • the nature of policy, planning or service decision multiplied by the potential for population impact, • a preliminary assessment to determine the possible • populations affected and the potential equity dimensions • identification of appropriate stakeholders
SCREENING
Setting the scope of the EFHIA, including: • establishing terms of reference (including indigenous aspects) • clarifying dimensions of equity (access, resources, outcomes) • agreeing definitions such as search terms, elements of • SEP/SES • brainstorming for likely or possible impacts of the policy • identifying outcome measures and consideration of how these could be used for monitoring, and • planning for the EFHIA e.g. timing, management, reporting and accountability aspects.
SCOPING
Detailed analysis of policy or practice to include: • Identification of policy context • Identification of target population(s) • Data collection on relevant population groups or sub-populations (included and excluded) • Identification of policy or practice variable(s) of interest
IMPACT IDENTIFICATION
Steps include:
Search literature for evidence of relationship between populations group, SEP & variable of interest
Consultation with stakeholders, target population, key informants on the relationship between the variable of interest, the potential or actual impacts, differential impacts and population group(s)
Critically appraise literature and other evidence
Weighting and synthesis of evidence and consideration of equity impacts in this setting at this time (such as the nature of impact versus the likelihood of impacts occurring)
ASSESSMENT OF IMPACTS
Review by colleagues, experts/stakeholders as appropriate
Produce a statement of potential impacts on policy on equity
RECOMMENDATIONS
To recommend changes based on the identified likely equity impacts and links to health
MONITORING & EVALUATION
Strategies for monitoring uptake and impact of EFHIA recommendations and systems for evaluating outcomes
Fig. 1. The EFHIA framework.
4.2. Scoping with an equity-focus The purpose of scoping is to set parameters for the assessment. If the equity dimension is to be covered this must include defining bequityQ outcomes to be expected (to reduce the gap in health between rich and poor, to reduce the social gradient in health across all
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groups or to improve the health of those with the poorest health). It is also necessary to agree search terms for the literature review e.g. health inequalities, disparities, inequity, socioeconomic position and so on. Further one has to negotiate what will count as bevidenceQ and how it will be weighted, especially in situations where there is no clear equity-related evidence (Mahoney et al., 2004). Having a deliberate equity-focus in the scoping step is critical because it drives the range and types of information collected. The framework provides guidance on how to identify potential sources of equity-related evidence and suggests search terms and strategies that are outside of the traditional approach (National Health and Medical Research Council, 2003). A deliberate equity-focus also allows for an explicit discussion of equity-related values, of the assessors’ assumptions and of the wider context in which the EFHIA is being undertaken. The case study sites found difficulty in ensuring that those who are most marginalised, had opportunity to make an input to the scoping step. This difficulty was compounded by the ethical point that involvement in scoping offers no clear or immediate benefit to these people. They found it was important to move beyond seeing btarget groupsQ, such as women or youth, as homogenous and to identify potential inequity within these groups. Further problems were that equity issues were not reflected in much of the published literature and that traditional search strategies often failed to find relevant evidence. The assessors then had to decide on how they would deal with disagreements as to how the evidence that was found should be valued and to decide what to do when the evidence was limited or conflicting. 4.3. Identification of impacts with an equity-focus The purpose of this step is to collect information and identify potential health impacts. An equity-focus at the stage of identifying impacts involves the collection of information from different sources and profiling of relevant communities and groups within the population. In order to do this information must be collected from a wide range of sources to identify potential health and equity impacts. Particular attention must be paid to differential distribution of potential health impacts as well as their nature, magnitude and likelihood in order to assess whether these differential impacts are inequitable. This information is then used to produce a profile describing health inequalities between identified population groups such as socio-economic, ethnic and gender groups (Mahoney et al., 2004). Several of the case study sites found difficulty in obtaining information for profiling because existing sources had not broken down the data into the agreed population groups or conceptualised health inequalities in the same way as the EFHIA. For example, available sources may only record differences between groups by place of residence and have no breakdown by other characteristics such as age, income or ethnicity. Significant inequalities may therefore be concealed. 4.4. Assessment with an equity-focus The purpose of the assessment step is to assess the information collected during the identification of impacts step and establish the nature (positive, negative, neutral or
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unknown), severity and likelihood of the identified potential health impatcs. The equity dimensions of the assessment step during EFHIA requires the bringing together of disparate information to measure differences, to assess the fairness and avoidability of these differences, to identify divergence and convergence between different sources and to weight the impacts for equity (Mahoney et al., 2004). The case study sites found the assessment step challenging because of the limited guidance available about what to do when the different sources of information (for example dexpertT and dlayT information) did not converge and how the assessors should interpret these different sources. When this happened the agreed definition of equity and objectives for the EFHIA (developed during scoping) became critical. Assessors needed to discuss and clarify values and assumptions. They further needed to cope with situations in which no consensus could be found or situations in which unexpected impacts became apparent. 4.5. Making recommendations with an equity-focus The purpose of this step is to develop recommendations that are linked to the agreed bequity-focusQ or the objectives of the EFHIA. The recommendations have to be based on the findings of the assessment and must be feasible for adoption by decision-makers (Mahoney et al., 2004). The EFHIA case study sites found that it was sometimes necessary to make a recommendation that favoured one group over another. For example one might recommend redistribution of resources to benefit those groups most likely to experience inequalities and this was often seen as difficult. Those doing the EFHIA felt they needed further skills to move beyond the usual description of inequalities to recommending actions to address them.
5. Discussion Feedback from the case study sites and from the international capacity building meeting indicated that equity-focused HIA was considered to be a useful tool for systematically incorporating equity into HIA. Not enough time has yet passed to determine the extent to which recommendations made through the EFHIA process have been acted upon by decision-makers. While the framework enables explicit consideration of equity at each step of HIA, it places heavy demands of time and other resources. One has to decide when an EFHIA is more appropriate than an HIA. Some sites found that just undertaking the screening step was useful because it prompted decision-makers to think differently. Developing tools for rapid screening of proposals for unintended equity implications may provide bearly winsQ and result in proposals, which give more weight to an equity-focus. It is also hoped that experience of EFHIA may encourage decision-makers to consider equity earlier in the policy development or planning process so that the EFHIA is not needed at a later stage. One of the greatest challenges faced by the case study sites was synthesising conflicting evidence from different sources (scientific literature, document analysis,
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focus groups, etc). While an approach to this has been developed in the EFHIA framework (Mahoney, 2004) this needs to be further refined. Where evidence is lacking or divergent the EFHIA process must be transparent. It may be necessary to make qualified impact statements such as bIf the evidence from the scientific literature is to be valued more highly than evidence from other sources, then the conclusion is. . .on the other hand if evidence from focus groups is preferred, then the conclusion is. . .Q. The role of the EFHIA assessors however is not to force consensus (Connelly and Richardson, 2005) or remove the need for judgement by decision-makers (Kemm, 2003). The EFHIA report should make the rationale for prioritising the evidence clear, including how it was prioritised and any dtrade-offsT transparent. For example, valuing the information from stakeholders more than information from the published literature may mean that the equity objective of the proposal is not realised. Information may be prioritised on the basis of salience, acceptability and appropriateness to the decisionmakers and key stakeholders (Petticrew and Roberts, 2003). Decision-making is influenced as much by politics as by the bevidenceQ. Workforce capacity and skills were highlighted at the international meeting. If EFHIA is to become part of regular public health practice and policy development then HIA practitioners need to increase their skills in making bequity-focusedQ decisions and developing practical strategies to help decision-makers to improve their proposals. Meeting participants felt that the framework brought together two very complex ideas, equity and HIA, and the complexity is compounded by combining them. Practitioners have long recognised the need to move from describing inequities to recommending action to reduce them. However even the most committed practitioners find this difficult to do.
6. Conclusion As with all HIA, it will be important to evaluate the impact and outcomes of the actual EFHIAs undertaken to date. The EFHIA shows promise but by itself does not reduce health inequity. It is the use that is made of the EFHIA report that will make the difference. Public health practitioners must work closely with each other and with policy makers and other public health practitioners to identify key strategies for promoting health equity.
Acknowledgments We thank: the Australian Government Department of Health and Ageing who funded the project through the Public Health Education and Research Program (PHERP); our colleagues in ACHEIA, particularly those who tested the draft EFHIA framework in the case study sites; and Ben Harris-Roxas in undertaking the literature review. All outputs (including publications) developed using PHERP funding are freely available and can therefore be accessed from any of the following websites http://chetre. med.unsw.edu.au/hia/index.htm, http://www.deakin.edu.au/hbs/hia/ or www.niph.org.au.
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References ACHEIA. http://chetre.med.unsw.edu.au/hia/index.htm, http://www.deakin.edu.au/hbs/hia/ or www.niph.org.au); 2005. Acheson D. Health inequalities impact assessment. Bull World Health Organ 2000;78:75 – 6. Acheson D, Barker D, Chambers J, Grahma H, Marmot M, Whitehead M. Report of independent inquiry into inequalities in health. London7 The Stationery Office; 1998. Association of Public Health Observatories. Local basket of health inequalities indicators. London, Association of Public Health Observatories and the NHS Health Development Agency. http://www.Iho.org.uk/ Health_Inequalities/BasketOfIndicators/BasketIndicators.htm; 2003. Connelly S, Richardson T. Value driven SEA: time for an environmental justice perspective? Environ Impact Asses Rev 2005;25:391 – 409. Douglas M, Scott-Samuel A. Addressing health inequalities in health impact assessment. J Epidemiol Community Health 2001;55:450 – 1. Douglas M, Conway L, Gorman D, Gavin S, Hanlon P. Developing principles for health impact assessment. J Public Health Med 2001;23:148 – 52. European Centre for Health Policy. Health impact assessment; main concepts and suggested approaches: the Gothenburg consensus paper. Brussels; European Centre for Health Policy and World Health Organization Regional Office for Europe; 1999. Global Equity Gauge Alliance. The equity gauge: concepts principles and guidelines. Durban, Global Equity Alliance and Health Systems Trust. www.gega.org.za/download/gega_gauge.pdf; 2003. Hamer L, Jaconsen B, Flowers J, Johnstone F. Health equity audit made simple: a briefing for primary care trusts and local strategic partnerships. London7 Health Development Agency; 2003. Harris E, Simpson S. Health inequality: an introduction. Health Promot J Aust 2003a;14:208 – 12. Harris E, Simpson S. NSW health impact assessment project: phase 1 report. Sydney7 Centre for Health Equity Training Research and Evaluation, University of New South Wales; 2003b. Harris-Roxas B, Simpson S, Harris E. Equity focused health impact assessment: a literature review. Sydney7 Centre for Health Equity Training Research and Evaluation, University of New South Wales; 2004. Health Development Agency. Using health impact assessment to improve public health. Int J Health Promot Educ 2001;8:2. Kemm J. Health impact assessment: a tool for healthy public policy. Health Promot Int 2001;16:79 – 85. Kemm J. Perspectives on health impact assessment. Bull World Health Organ 2003;81:387. Mahoney M, Durham G. Health impact assessment: a tool for policy development in Australia. Victoria7 Faculty of Health and Behavioural Sciences, Deakin University; 2002. Mahoney M, Morgan R. Health impact assessment in Australia and New Zealand: an exploration of methodological concerns. Int J Health Promot Educ 2001;8:8 – 11. Mahoney M, Simpson S, Harris E, Aldrich R, Stewart-Williams J. Equity focussed health impact assessment framework. Sydney7 Australian Collaboration for Health Equity Impact Assessment (ACHEIA); 2004. National Health and Medical Research Council. Using socio-economic evidence in clinical practice guidelines. Canberra7 National Health and Medical Research Council; 2003. National Public Health Partnership. Health impact assessment: legislative and administrative frameworks: consultation paper. Canberra7 National Public Health Partnership; 2003. National Public Health Service for Wales. Health inequalities impact assessment checklist: guidance notes. Cardiff7 National Public Health Service for Wales; 2003. Ntuli A, Khosa S, McCoy D. The equity gauge. Durban7 The Health Systems Trust; 2003. Petticrew M, Roberts H. Evidence, hierarchies, and typologies: horses for courses. J Epidemiol Community Health 2003;57:527 – 9. Public Health Advisory Committee. A guide to health impact assessment: a policy tool for New Zealand. Wellington, New Zealand7 National Advisory Committee on Health and Disability; 2004. Ritsatakis A, Barnes R, Douglas M, Scott-Samuel A. Health impact assessment An approach to promote intersectoral policies to reduce socioeconomic inequalities in health. In: Mackenbach J, Bakker J, editors. M reducing inequalities in health: a European perspective. . .London. London7 Routledge; 2002.
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Scott-Samuel A, Birley M, Arden K. The Merseyside guidelines for health impact assessment. Liverpool7 Merseyside Health Impact Assessment Steering Group; 1998. Simpson S, Harris E, Harris-Roxas B. Health impact assessment: an introduction to the what, why and how. Health Promot J Aust 2004;15:162 – 7. Welsh Health Impact Assessment Support Unit. Improving health and reducing inequalities. A practical guide to health impact assessment. Cardiff Institute of Society, Health and Ethics, School of Social Sciences, Cardiff University, Cardiff; 2004. West Midlands Directors of Public Health Group. Using Health Impact Assessment to make Better Decisions. Birmingham, NHS Executive, West Midlands and Health Impact Assessment Research Unit, Birmingham University; 2000. Whitehead M. The concepts and principles of equity and health. Copenhagen7 World Health Organisation, Regional Office for Europe; 1990. World Health Organisation. The Jakarta Declaration on leading health promotion into the 21st century. Geneva7 World Health Organisation; 1997.
Equity-focused health impact assessment: A tool to assist policy makers in addressing health inequalities Sarah Simpson a,*, Mary Mahoney b, Elizabeth Harris b, Rosemary Aldrich c, Jenny Stewart-Williams d a
Centre for Health Equity Training Research and Evaluation, School of Public Health and Community Medicine, University of NSW, Australia b Health Impact Assessment Research Unit, Faculty of Health and Behavioural Sciences, Deakin University, Victoria, Australia c University of Newcastle, NSW, Australia d Newcastle Institute of Public Health, University of Newcastle, NSW, Australia Available online 15 August 2005
Abstract In Australasia (Australia and New Zealand) the use of health impact assessment (HIA) as a tool for improved policy development is comparatively new. The public health workforce do not routinely assess the potential health and equity impacts of proposed policies or programs. The Australasian Collaboration for Health Equity Impact Assessment was funded to develop a strategic framework for equity-focused HIA (EFHIA) with the intent of strengthening the ways in which equity is addressed in each step of HIA. The collaboration developed a draft framework for EFHIA that mirrored, but modified the commonly accepted steps of HIA; tested the draft framework in six different health service delivery settings; analysed the feedback about application of the draft EFHIA framework and modified it accordingly. The strategic framework shows promise in providing a systematic process for identifying potential differential health impacts and assessing the extent to which these are avoidable and unfair. This paper presents the EFHIA framework and discusses some of the issues that arose in the case study sites undertaking equity-focused HIA. D 2005 Elsevier Inc. All rights reserved. Keywords: Health impact assessment; Equity
* Corresponding author. Tel.: +61 2 9385 0420; fax: +61 2 9385 0140. E-mail address: [email protected] (S. Simpson). 0195-9255/$ - see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.eiar.2005.07.010
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1. Introduction Australia and New Zealand have been international leaders in the development of health impact assessment (HIA) as part of environmental health frameworks. In these countries health impacts have traditionally been considered as part of environmental impact assessment (EIA) (Harris and Simpson, 2003b; Mahoney and Durham, 2002). Recently the two countries have become increasingly interested in exploring the use of HIA for policy development (National Public Health Partnership, 2003; Mahoney and Durham, 2002; Public Health Advisory Committee, 2004). However, the use of HIA as a tool for policy development is still comparatively new within public health, and public health workers do not routinely assess the potential health and equity impacts of proposed policies, programs or projects (hereafter referred to as proposals). Health impact assessment uses a structured, stepwise impact assessment process to assess the potential health impacts of proposed policies (for example a new taxation policy) (European Centre for Health Policy, 1999; Mahoney and Morgan, 2001). Other characteristics integral to this application of HIA include, ! use of a broad definition of health—to include assessments of hazards and risk as well as ways in which health could be promoted and the social forces that impact negatively on health reduced (Harris and Simpson, 2003b); ! assessment of the health impacts on populations directly and indirectly affected; ! assessment of the distribution of these impacts across different population groups (Simpson et al., 2004). Health impact assessment provides a structured process for improving a proposal by providing decision-makers with information on potential health impacts and recommendations for improving the proposal, thereby contributing to improved policy development. In addition, while equity is considered a core value of HIA (Ritsatakis et al., 2002; Douglas and Scott-Samuel, 2001; Douglas et al., 2001; European Centre for Health Policy, 1999; Health Development Agency, 2001; Kemm, 2001), it is also important to make explicit the consideration of equity, so that HIA can illuminate the equity impacts of a proposal. During the mid 1990s key commentators on HIA advocated its use to assess the potential equity impacts of proposals (particularly policy proposals)—this was referred to as health inequalities impact assessment (Acheson et al., 1998; Acheson, 2000; World Health Organisation, 1997). There have been some debate about the need for a yet another separate form of impact assessment. Some practitioners of HIA have indicated a preference for equity in every HIA rather than health inequalities impact assessment (Douglas and Scott-Samuel, 2001; Ritsatakis et al., 2002). There is agreement among practitioners that the role of HIA, as well as being population focused, is to identify any differential impacts that may arise for specific groups likely to be affected by the proposal (European Centre for Health Policy, 1999; Douglas et al., 2001; Kemm, 2001; Ritsatakis et al., 2002). Examples of tools and guidance that have been developed to facilitate an equity-focus within HIA and in public health practice include the Bro Taf Health Inequalities Impact Assessment tool (National Public Health Service for Wales, 2003; Welsh Health Impact Assessment Support Unit, 2004), the Equity Audit (Association of
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Public Health Observatories, 2003; Hamer et al., 2003) and the Equity Gauge (Global Equity Gauge Alliance, 2003; Ntuli et al., 2003). However experience of HIA in the Australasian context together with a review of the published literature and of practice of HIA in other contexts indicate that addressing equity in HIA is currently an aspiration rather than a reality (Harris-Roxas et al., 2004; Ritsatakis et al., 2002). Specific findings were that: ! equity is not effectively addressed in other forms of impact assessment and issues of avoidability and fairness are rarely examined; ! there is often an uncritical assumption that increased community participation will in itself ensure an equity perspective; ! there is a lack of structured guidance or tools to assist practitioners to ensure bequity in every HIAQ; ! assessment stops at identifying differential impacts and fails to move to determining avoidability, fairness and ways to address inequities (Harris-Roxas et al., 2004). This debate is not unique to HIA. It is occurring elsewhere in the impact assessment literature. Connelly and Richardson (2005) recently questioned the assumption that the process of deliberation in Strategic Environmental Assessments (SEA) would result in sustainable and equitable outcomes for all. They advocated the use of environmental justice as a structured process during SEA in order to make the different and hard tradeoffs explicit thereby giving some guidance on how sustainability might be achieved. Based on the belief that the consideration of equity needed to be made explicit in HIA, and encouraged by the growing interest in the broader application of HIA in Australasia, in 2002 a collaboration of three universities proposed the development of a strategic framework for health inequalities impact assessment. The partners in the collaboration were the Institute of Public Health at Newcastle University (NSW), Deakin University (Victoria) and the Centre for Health Equity Training Research and Evaluation at the University of New South Wales. The proposal was accepted and funded by the Australian Government Department of Health and Ageing (DOHA) and the framework was subsequently renamed equity-focused HIA (EFHIA). The intention in developing the framework was not to develop yet another form of HIA but to produce more explicit guidance for practitioners on how they could systematically address equity within the existing process of HIA. This paper will present the development of the EFHIA framework developed and discuss some of the issues that arose in case studies of its use.
2. Defining equity and equity-focused health impact assessment An equity approach recognises that not everyone has the same level of health or level of resources to deal with their health problems. It may therefore be important to deal with people differently in order to work towards equal outcomes, where: . . .the aim of policy for equity and health is. . .to reduce or eliminate those [health differences], which result from factors which are considered to be both avoidable and unfair (Whitehead, 1990).
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Equity-focused decisions are based on the values and assumptions of the decisionmakers. It is therefore important that these values and assumptions are made explicit and that it is recognised that there may be competing values and assumptions that will make the decision contested (Harris and Simpson, 2003a). Equity-focused HIA uses health impact assessment methodology in a structured way to explore the potential differential impacts of a proposal on the health of specific groups within a population and to assess if these differential impacts are inequitable. Equity-focused HIA: ! Identifies the distribution of health impacts across the population. ! Considers if the identified potential health impacts are shared unequally across the population (e.g. some groups may potentially be more adversely or more positively affected than others). ! Assesses whether these potential differential health impacts are avoidable and unfair— that is, inequitable. ! Reduces the potential for these differential impacts to become health inequities by using the findings from the EFHIA to amend, ameliorate and improve the proposed policy, program or project (ideally before it is implemented).
3. Development of the EFHIA framework The Australasian Collaboration for Health Equity Impact Assessment (ACHEIA) was formed to provide guidance to the EFHIA project. It included the six investigators; the project officer; international advisers from university and government sectors in the areas of equity, policy development, impact assessment and HIA; the case study partners from the EFHIA sites; organisational nominees (e.g. DOHA); and indigenous consultants from Australia and New Zealand. A full list of the members of ACHEIA is available from the project website (ACHEIA, 2005). The process for developing and testing of the EFHIA framework included: 1. Developing a draft framework for equity-focused HIA that adapted the commonly accepted steps of HIA—screening, scoping, identification and assessment/appraisal of impacts, negotiation, development of recommendations and evaluation (West Midlands Directors of Public Health Group, 2000; Scott-Samuel et al., 1998). 2. Developing a manual outlining the draft framework to assist the case study sites. 3. Testing the EFHIA framework in six case study sites in a range of health settings (listed in Table 1). An EFHIA was undertaken with guidance from one of the investigators at each of these sites, which offered a range of health settings. 4. Undertaking a systematic review of the literature to identify other models for incorporating equity considerations into HIA, and to determine the extent to which equity considerations were incorporated in reported HIAs (Harris-Roxas et al., 2004). 5. Holding a 2 day international capacity building meeting to showcase the draft EFHIA framework. This meeting included a 1 day training program on applying the framework.
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Table 1 The six EFHIA case study sites 1. New Zealand Ministry of Health. EFHIA of Health Eating Action. Policy, a policy which was written with specific reference to Maori health. 2. Royal Australasian College of Physicians. EFHIA of Support Scheme for Rural Specialists, a continuing education and professional development program for specialists in rural Australia using videoconferencing as a delivery mechanism. 3. National Health and Medical Research Council. EFHIA of a consumer brochure and booklet to accompany the councils Dietary Guidelines for Older Australians. The aim of the publications was to provide information about diet and nutrient intake to independent healthy older Australians. 4. John Hunter Hospital. EFHIA of existing outpatient Cardiac Rehabilitation Program, which aimed to optimize the recovery of patients following an acute cardiac event and to reduce the risk of further cardiac events. 5. Australian Capital Territory Health Promotion Board. EFHIA of the annual Community Funding Program of grants and/or sponsorships. 6. EFHIA of South Australian Breastfeeding Action Plan 2004–2006 where the EFHIA focused on assessing the major components of a plan to promote breastfeeding in families and community settings.
6. Analysing feedback from the sites and the workshop and using this analysis to modify the EFHIA framework.
4. The framework 4.1. Screening with an equity-focus The first step in EFHIA is screening in order to determine whether a HIA is actually required. The equity dimension of screening in EFHIA considers whether the potential health impacts are likely to be differentially distributed by factors such as socioeconomic status, ethnicity, gender, geography and if these differential impacts are bunfairQ and bavoidableQ—that is binequitableQ (Mahoney et al., 2004). Beginning with an equity-focus requires practitioners to look beyond the health impacts for the overall population to systematic health differences in sub-groups of the population and groups who are not specifically included in the proposal. This approach is not dissimilar to that proposed in the Bro Taf guidance and Welsh Guidance on HIA where a range of potentially bvulnerableQ population groups are identified for practitioners to consider during the screening step (Welsh Health Impact Assessment Support Unit, 2004; National Public Health Service for Wales, 2003; Fig. 1). Experience at the six case study sites during the screening step of EFHIA showed the importance of investing time in defining why an equity-focused HIA has been chosen and to develop a shared understanding of equity. It is also important that the equity-rationale be made explicit in the screening report. Some found it difficult to acknowledge that well-intentioned proposals could have unintended and unanticipated consequences that could be judged inequitable. There was a strong temptation to revise the proposal at the screening and scoping steps as potential equity impacts are identified.
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Determining the suitability of the policy or practice for an EFHIA and the feasibility of undertaking it. This step includes consideration of: • the nature of policy, planning or service decision multiplied by the potential for population impact, • a preliminary assessment to determine the possible • populations affected and the potential equity dimensions • identification of appropriate stakeholders
SCREENING
Setting the scope of the EFHIA, including: • establishing terms of reference (including indigenous aspects) • clarifying dimensions of equity (access, resources, outcomes) • agreeing definitions such as search terms, elements of • SEP/SES • brainstorming for likely or possible impacts of the policy • identifying outcome measures and consideration of how these could be used for monitoring, and • planning for the EFHIA e.g. timing, management, reporting and accountability aspects.
SCOPING
Detailed analysis of policy or practice to include: • Identification of policy context • Identification of target population(s) • Data collection on relevant population groups or sub-populations (included and excluded) • Identification of policy or practice variable(s) of interest
IMPACT IDENTIFICATION
Steps include:
Search literature for evidence of relationship between populations group, SEP & variable of interest
Consultation with stakeholders, target population, key informants on the relationship between the variable of interest, the potential or actual impacts, differential impacts and population group(s)
Critically appraise literature and other evidence
Weighting and synthesis of evidence and consideration of equity impacts in this setting at this time (such as the nature of impact versus the likelihood of impacts occurring)
ASSESSMENT OF IMPACTS
Review by colleagues, experts/stakeholders as appropriate
Produce a statement of potential impacts on policy on equity
RECOMMENDATIONS
To recommend changes based on the identified likely equity impacts and links to health
MONITORING & EVALUATION
Strategies for monitoring uptake and impact of EFHIA recommendations and systems for evaluating outcomes
Fig. 1. The EFHIA framework.
4.2. Scoping with an equity-focus The purpose of scoping is to set parameters for the assessment. If the equity dimension is to be covered this must include defining bequityQ outcomes to be expected (to reduce the gap in health between rich and poor, to reduce the social gradient in health across all
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groups or to improve the health of those with the poorest health). It is also necessary to agree search terms for the literature review e.g. health inequalities, disparities, inequity, socioeconomic position and so on. Further one has to negotiate what will count as bevidenceQ and how it will be weighted, especially in situations where there is no clear equity-related evidence (Mahoney et al., 2004). Having a deliberate equity-focus in the scoping step is critical because it drives the range and types of information collected. The framework provides guidance on how to identify potential sources of equity-related evidence and suggests search terms and strategies that are outside of the traditional approach (National Health and Medical Research Council, 2003). A deliberate equity-focus also allows for an explicit discussion of equity-related values, of the assessors’ assumptions and of the wider context in which the EFHIA is being undertaken. The case study sites found difficulty in ensuring that those who are most marginalised, had opportunity to make an input to the scoping step. This difficulty was compounded by the ethical point that involvement in scoping offers no clear or immediate benefit to these people. They found it was important to move beyond seeing btarget groupsQ, such as women or youth, as homogenous and to identify potential inequity within these groups. Further problems were that equity issues were not reflected in much of the published literature and that traditional search strategies often failed to find relevant evidence. The assessors then had to decide on how they would deal with disagreements as to how the evidence that was found should be valued and to decide what to do when the evidence was limited or conflicting. 4.3. Identification of impacts with an equity-focus The purpose of this step is to collect information and identify potential health impacts. An equity-focus at the stage of identifying impacts involves the collection of information from different sources and profiling of relevant communities and groups within the population. In order to do this information must be collected from a wide range of sources to identify potential health and equity impacts. Particular attention must be paid to differential distribution of potential health impacts as well as their nature, magnitude and likelihood in order to assess whether these differential impacts are inequitable. This information is then used to produce a profile describing health inequalities between identified population groups such as socio-economic, ethnic and gender groups (Mahoney et al., 2004). Several of the case study sites found difficulty in obtaining information for profiling because existing sources had not broken down the data into the agreed population groups or conceptualised health inequalities in the same way as the EFHIA. For example, available sources may only record differences between groups by place of residence and have no breakdown by other characteristics such as age, income or ethnicity. Significant inequalities may therefore be concealed. 4.4. Assessment with an equity-focus The purpose of the assessment step is to assess the information collected during the identification of impacts step and establish the nature (positive, negative, neutral or
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unknown), severity and likelihood of the identified potential health impatcs. The equity dimensions of the assessment step during EFHIA requires the bringing together of disparate information to measure differences, to assess the fairness and avoidability of these differences, to identify divergence and convergence between different sources and to weight the impacts for equity (Mahoney et al., 2004). The case study sites found the assessment step challenging because of the limited guidance available about what to do when the different sources of information (for example dexpertT and dlayT information) did not converge and how the assessors should interpret these different sources. When this happened the agreed definition of equity and objectives for the EFHIA (developed during scoping) became critical. Assessors needed to discuss and clarify values and assumptions. They further needed to cope with situations in which no consensus could be found or situations in which unexpected impacts became apparent. 4.5. Making recommendations with an equity-focus The purpose of this step is to develop recommendations that are linked to the agreed bequity-focusQ or the objectives of the EFHIA. The recommendations have to be based on the findings of the assessment and must be feasible for adoption by decision-makers (Mahoney et al., 2004). The EFHIA case study sites found that it was sometimes necessary to make a recommendation that favoured one group over another. For example one might recommend redistribution of resources to benefit those groups most likely to experience inequalities and this was often seen as difficult. Those doing the EFHIA felt they needed further skills to move beyond the usual description of inequalities to recommending actions to address them.
5. Discussion Feedback from the case study sites and from the international capacity building meeting indicated that equity-focused HIA was considered to be a useful tool for systematically incorporating equity into HIA. Not enough time has yet passed to determine the extent to which recommendations made through the EFHIA process have been acted upon by decision-makers. While the framework enables explicit consideration of equity at each step of HIA, it places heavy demands of time and other resources. One has to decide when an EFHIA is more appropriate than an HIA. Some sites found that just undertaking the screening step was useful because it prompted decision-makers to think differently. Developing tools for rapid screening of proposals for unintended equity implications may provide bearly winsQ and result in proposals, which give more weight to an equity-focus. It is also hoped that experience of EFHIA may encourage decision-makers to consider equity earlier in the policy development or planning process so that the EFHIA is not needed at a later stage. One of the greatest challenges faced by the case study sites was synthesising conflicting evidence from different sources (scientific literature, document analysis,
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focus groups, etc). While an approach to this has been developed in the EFHIA framework (Mahoney, 2004) this needs to be further refined. Where evidence is lacking or divergent the EFHIA process must be transparent. It may be necessary to make qualified impact statements such as bIf the evidence from the scientific literature is to be valued more highly than evidence from other sources, then the conclusion is. . .on the other hand if evidence from focus groups is preferred, then the conclusion is. . .Q. The role of the EFHIA assessors however is not to force consensus (Connelly and Richardson, 2005) or remove the need for judgement by decision-makers (Kemm, 2003). The EFHIA report should make the rationale for prioritising the evidence clear, including how it was prioritised and any dtrade-offsT transparent. For example, valuing the information from stakeholders more than information from the published literature may mean that the equity objective of the proposal is not realised. Information may be prioritised on the basis of salience, acceptability and appropriateness to the decisionmakers and key stakeholders (Petticrew and Roberts, 2003). Decision-making is influenced as much by politics as by the bevidenceQ. Workforce capacity and skills were highlighted at the international meeting. If EFHIA is to become part of regular public health practice and policy development then HIA practitioners need to increase their skills in making bequity-focusedQ decisions and developing practical strategies to help decision-makers to improve their proposals. Meeting participants felt that the framework brought together two very complex ideas, equity and HIA, and the complexity is compounded by combining them. Practitioners have long recognised the need to move from describing inequities to recommending action to reduce them. However even the most committed practitioners find this difficult to do.
6. Conclusion As with all HIA, it will be important to evaluate the impact and outcomes of the actual EFHIAs undertaken to date. The EFHIA shows promise but by itself does not reduce health inequity. It is the use that is made of the EFHIA report that will make the difference. Public health practitioners must work closely with each other and with policy makers and other public health practitioners to identify key strategies for promoting health equity.
Acknowledgments We thank: the Australian Government Department of Health and Ageing who funded the project through the Public Health Education and Research Program (PHERP); our colleagues in ACHEIA, particularly those who tested the draft EFHIA framework in the case study sites; and Ben Harris-Roxas in undertaking the literature review. All outputs (including publications) developed using PHERP funding are freely available and can therefore be accessed from any of the following websites http://chetre. med.unsw.edu.au/hia/index.htm, http://www.deakin.edu.au/hbs/hia/ or www.niph.org.au.
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