21 March 2013

"There are already mechanisms in place": same old arguments against health impact assessment?

The Australian Senate
The Australian Senate Standing Committees on Community Affairs released a report on Australia's domestic response to the World Health Organization's (WHO) Commission on Social Determinants of Health report "Closing the gap within a generation" last night. The response to the report seems lukewarm to me, though that may be coloured by my personal sense that this represents another missed opportunities for intersectoral action for health in Australia. The Social Determinants of Health Alliance released a fairly upbeat press release.

From an HIA and Health in All Policies perspective there are a few interesting sections. I'll post two reasonable lengthy excerpts below so you can make up your own mind. This is from the Government response section:

Adopting a Health in All Policies approach
4.46      The pre-eminent idea put to the committee to address the social determinants of health in Australia was for the Commonwealth government to adopt a similar mechanism as the South Australian 'Health in All Policies' (HiAP) approach to government action. HiAP is a horizontal health policy strategy that incorporates health as a shared goal across all parts of Government and addresses complex health challenges through an integrated policy response across portfolio boundaries.[54] As explained by representatives from the South Australian Government:
Health in All Policies is essentially an approach to working collaboratively on policy issues across government to enable joined up policy responses to complex, so-called wicked, policy goblins. The problems faced by the health department results from these wicked problems, such as obesity, chronic disease and health inequities. All of these have serious impact on health services and health financing and budgets, but health departments do not actually have the policy levers to address them. Other sectors and departments do have the policy levers—such as transport, agriculture, employment and education—however many of these agencies that are able to take action on these determinants of health and wellbeing do not see health as their business...Our version of Health in All Policies looks at how we can assist other agencies in meeting their goals, in a way that supports health and wellbeing...In South Australia the Health in All Policies approach is applied in the internal government policy process, focusing strongly on Health being a partner rather than a director in the public policy process.[55]
4.47      Under the South Australian model, in order to ensure that policies have considered potential health impacts, health impact assessments are used. Health impact assessments consider the potential health consequences of a policy.
4.48      A large number of stakeholders called for the Commonwealth to adopt HiAP approach similar to the one used by the South Australian government.[56]
Later in the chapter:
 4.54      One argument put forward for the adoption of a health impact or equity assessment framework was that it would 'create a little bit more awareness and consciousness around how decisions we make in every government department impact on people's health and equity issues.'[62] The actions already taken by a number of state governments point towards some jurisdictions being well ahead of the Commonwealth when it comes to ensuring that there is a sufficient understanding of the social determinants of health within government programs. Improving the awareness of health in areas outside the traditional health field is to be encouraged.
4.55      Although the Department conceded that health impact assessments might be useful, it was argued that this needs to be considered alongside their time- and cost-heavy nature:
Health impact assessments have been promoted as a means of assessing the health impacts of policies, plans and projects using quantitative, quantitative and participatory techniques. While we think that they may be a useful tool, we believe that they have the potential to be expensive and time-consuming, and we believe that this needs to be taken into account in any further consideration of these.[63]
4.56      This point was expounded upon in the Department's supplementary submission:
In the case of both the South Australian Government and Tasmanian Health in All Policies Collaboration, key drivers have been established through legislation; in particular Public Health Acts, as well as state based strategic plans and/or targets. Duplication of such approaches at a national level could add further complexity to an already complicated environment without a clear mandate for action.[64]
4.57      The Australian Social Inclusion Board made a similar case against the use of a South Australian style approach:
The development of a more formally structured framework, such as the South Australian approach, could introduce ambiguity into existing Commonwealth mechanisms and therefore detract from the social inclusion narrative. It could also result in current measurement and reporting framework and social inclusion principles holding less currency.[65]
4.58      However, representatives from the Department argued that there was already adequate consideration given to health in public policy making:
An approach is taken, certainly by our department, that recognises the interconnectedness and complexity of the social determinants of health through integrated approaches to the development and implementation of social policy and programs, both at the Commonwealth level but also across all levels of government. Key aspects of the approach include a number of things: firstly, strong governance arrangements. Some examples of those are the Australian Social Inclusion Board, the Social Policy and Social Inclusion Committee of Cabinet and also COAG's standing committees that look into these issues...[W]e believe that other approaches can and are also being used to achieve coordination across sectors and levels of government.[66]
4.59      The committee did not receive any evidence in the form of improved health outcomes that the South Australian model is more effective than comparative systems. The diversity of international and domestic responses to rising awareness of the social determinants of health points to a field of practice undergoing rapid evolution of thought. As noted by the Chief Executive Officer of ANPHA:
We are not sure which approaches will work best. We have almost got a set of natural experiments going on in Australia, which we think ought to be evaluated before we come to a conclusion on that. The South Australian method is one way of doing it...We are not quite sure what will do the trick here. It is one of the reasons we looked at Canada so closely. They do a bundle of different things, and other countries have done different things as well.[67] 
Committee view
4.60      The committee notes that the Department believes that it effectively takes a social determinants approach within its own policy making. However, the key point is that such an approach needs to be taken across government, and in particular in social, economic and employment policy decisions that affect social determinants (such as employment status, levels of welfare benefit, and access to education). The need for a social determinants approach lies not only within, but beyond, the health portfolio.
4.61      There are already mechanisms in place to ensure that important issues are considered across government when necessary, such as the requirements for inter-departmental consultation in the preparation of cabinet submissions, the requirement for Regulatory Impact Statements in conjunction with the introduction of legislation, and statements of compatibility with human rights.
4.62      Introducing a health in all policies approach of some sort would not therefore represent a completely new dimension to policy development. While the committee does not have a fixed view about how it should be done, the government's adoption of a social determinants approach should influence the policy development process, particularly in relevant areas such as education, employment, housing, family and social security.

There are a few familiar themes in this response that I've heard from government representatives over the years, from local health services to the World Health Organization:
  • HIA is expensive and time-consuming;
  • we're already doing addressing health in all our policy; and
  • HIA or HiAP would create duplication between levels of government and existing cross-sectoral policy initiatives.
All these assertions seem almost entirely without evidence to me. They may in fact be true but I haven't seen any empirical research that demonstrates them compellingly. Any discussions about expense and time investment should be in comparison to other interventions, rather than continuing to do nothing. HIA practitioners in many Federalist countries (e.g. Canada, U.S.A, Austria, Switzerland) have faced similar rationales to not develop an HIA or HiAP agenda at a federal level.

We need to be more assertive in calling out these kind of untested attitudes if we want to see further intersectoral action for health.