2nd Day Plenary Session 3 - HiAP/HIA and the Official Development Aid, Promoting Health in Developing Countries

Juan Garay, European Commission



Health and development are dynamic not static concepts.

Development has many dimensions and including ideological. Current definitions focus on economic aspects.

But controversial in health equity, time lag and adult health and productivity.

Non-income development and growth+ ...

Perennial arguments - right to health and priority aspiration for people
Growing factors - health linked with globalized risks, knowledge and resources and health inequities linked with instability (political and economic)

WHO Article 1 "....attainment of all people's of the highest possible levels of health."

Mortality has declined and life expectancy has improved but there are wide ranges depending on income 1990s was poor for improvements in life expectancy. Absolute levels have reduced though the proportion reduction generally greater for high income countries...

Equity dimension for these rates has hardly been touched!

80% of under 5 deaths are due to global inequity!

Millenium Development Goals only cover 60% of preventable deaths.

Health expenditure has hardly moved in low income countries but substantially in high income countries.

Even at the same level of GDP there are significant differences.

GDP and public funding are not key determinants of reduce under 5 mortality.

But, spending at or above $100 of public spending on health (care) have mortality rates below 50... (and no countries spending less than $40 have mortality rates that are that low.

Aid is very fragmented - over 100 global initiatives - competing, duplication, etc.

Policy coherence for development:
Trade
Migration
Security
Food security
Environmental change

Develop at global level develop expertise on HIA in the above area.


Peter Furu, University of Copenhagen

Almost $129 billion given in Official Development Assistance (ODA), planned ti grow at 2% per year compared to 8% in the past.

Health sector is the most complex with over 100

In 29 countries in sub-saharan Africa there are between 18-23 donors working in the health sector.

There are a range of different impact assessments that donor officials have to deal with.

Does the diversity in IAs facilitate effective aid giving? Or will they create more confusion than clarity?

How have donor partnerships used HIA and considered health?
OECD-Development Assistance Committee has an overarching objective (2011-2015)...future in which no country will depend on aid...

OECD-DAC, A practical guide to ex-ante poverty impact assessment
OECD, Guide on sustainable impact assessment

Poverty Impact Assessment:
Five capabilities considered - economic, human, political, socio-cultural and protective-security with environment and gender as cross-cutting issues.

Sustainable Impact Assessment
3 pillars of sustainable development
Economic
Social (health as one aspect)
Environmental

HIA stand-alone versus integrated?
How do we build capacity in both developing and developed countries?

Examples of capacity development in HIA in Lao PDR, Vietnam and Cambodia.

E-learning online course has been developed.

Challenges
...

Is diversity in IA create confusion or clarity?
How should health be addressed in an integrated way?


Carlos Dora, World Health Organization

ODA agencies not doing much around health - environmental and social focus, many gaps and lost opportunities.

Health could easily be integrated into existing mechanisms.

Use of EIA came through a negative impact of the use of pesticides and a resulting lawsuit.

Private capital flows are much bigger than public development aid. Development banks could play a role in monitoring the impacts of these flows, safeguards and performance standards are used to ensure projects protect environment and health.

Development bank safeguard systems.

WHO engaging with banks and undertaken adaptation of HIA tools, technical assistance and capacity building of staff to integrate health. 'Community health and development finance' (to be published in the near future).

HIA lends itself to transparency and accountability issues - provide a baseline for future monitoring, analysis of potential future impacts, development of high level management plan for addressing the identified impacts and mechanism for early and sustained engagement with stakeholders.

Document developed 'Managing the public health impacts of natural resource extraction activities' which outlines a broader framework within which HIA should be fitted.

Discussion draft can be found here:

http://www.oilwatchmesoamerica.org/doc/WHO_managing%20public%20health%20impacts%20%20of%20EI.pdf

Key concept is Healthy Green Growth/Economy - co-benefits of climate friendly policies

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2nd Day Plenary Session 2 - Developing integrated approaches to impact assessment

Marilyn Wise, Australia

How difficult it is to put things together - determinants, equity, climate change, trying to grapple put together disparate understandings and to try and change things not just locally but globally and society by society.

Trying to put together the complexity of life itself.


Rainer Fehr, Germany

For different target groups, HIA is not necessarily the concept of interest.

For society - health is the issue
For policymaking - health impact (or maybe) the issue
For expert community - how to estimate health impact is the issues

Integration - is the multi-layered HIA context, we need to consider integration for several reasons:

(professional) credibility
(practical) feasibility
(intellectual) parsimony
(monetary) efficiency


HIA can be integrated in many avenues - HI, HA and IA

Health impact issues:
Impact on (range of determinants, unified approach, synthesis) and of health (on health care system, interest of other non-health sectors e.g. education, employment)

Do we exploit our R&D on HIA and apply them to practice? Probably not as well as we could and should.

Health impact quantification - new and improved quality of science-policy interaction, unwanted patina of robust science, health impact modelling in environmental health and public health ...

From Granada workshop - Why? For whom? What to quantify? How? What scale level? etc..., uers are many including policymakers, public, persons working in policy environments...

Process of health impact quantification is as important as the numerical results as the real goal of improving 'real' health.

Health assessment:
....

Impact assessment:
Family of health related HIAs - Health in SEA, ...

Crude typology for integration:
None, partial (e.g. health in another assessment) and full (separate integrated framework for assessment)

Need to 'think' about integration but not necessarily to do it always...in research, HIA conference


Izabella Rohlfs, Spain

Difference between gender and sex is not always clear - biological and social

Gender perspective implies a transformational relationship to policies in terms of power, roles and autonomy for women and men; empowers women and tackles equity between men and women.

What is gender analysis?
Reveal the differential impacts between men and women with gender and sex and the interactions between them and other determinants such as socio-economic sttaus and ethnicity.

Gender as a construct rather than sex as a variable (e.g. in epidemiology that is a factor to be accounted for).

Gender in HIA - Are women and men differently affected by a policy? Is it equitable or not?

Screening - sensitive to avoid bias, alive to gender constructions and stereotypes.
Identification of stakeholders - failure to engage women who generally participate much less.

Scoping - Are there implicit and explicit stereotypes in the terms of reference?

Identifying impacts - policy contextualisation in terms of implementation, separate analysis for men and women, gender bias in expert and professional opnion, ...sex distribution, socio-economic position, age, ethnic origin, sexuality, etc.

Gathering evidence - "None of the social positions of interest nor the variables used to represent them are..." MacIntyre, ...

Synthesising evidence - critical approach to evidence reviews and synthesis, insufficient research should not be an excuse we must look for a measurement criteria and develop new evidence. Balance between subjective and objective evidence.

Analysis - contextualisation of health impacts

Towards a better future...

Marilyn Wise, Australia

Logic pathway - healthy population > health equity > equitable determinants of health > public policy

Solving earlier problems has created new problems.

Szreter's work demonstrated the relationship between enfranchisement and the earliests purposeful public health successes. Important to remember that during industrial revolution there was more equal exposure to poor environments between rich and poor.

Evidence on its own does not enough to bring about change - necessary but not sufficient.

The more the issue is at the regulatory/population level the less likely science to influence policy and vice versa the more individual/targeted level that the intervention is.

Intersectoral work has been challenging for the health sector.

Engaging has been framed as 'empowering' or 'self-determination' without regard for the role of the 'top'.

Need to develop a structured discussion between stakeholders.

Benefits but also challenges...



And issues of institutionalisation (no natural home), what is the trigger, mandated and capacity.

What promotes use of IA?
Relevance
Accuracy
Legitimacy
Structured Dialogue
Scientific credibility


But nothing about INEQUITY - systematic, persistent and routine on some groups compared to others.

Define equity/health equity
Differentiate between inequality and inequity
Include explicit attention to equity in each step of the process


"Fish don't see water" ?Labonte

Structured conversation to create shared meaning.
Needs political action

Sustainability may be the universal stimulus and IIA may prove to be the only logical form of IA to address the integrated systems that are responsible for 'creating' the problems and this needs to be linked to activism and political power.

2nd Day Parallel Session - Photos from the 'Screening for HIA/Rapid HIA tools'

Sorry, too intent on listening to be able to give even a snippet of the talks, you'll just have to read them when they are put on the conference website.

Next HIA Conference is in....Quebec, Canada

Got three applications:

Denmark
Switzerland
Canada

We are going out of Europe to North America!

August 2012 (best season to visit)!

Website www.hia2012.ca

Alain Poirier accepts on behalf of Quebec and Canada

What we can look forward to!

2nd Day Plenary Session 1 - HIA development and institutionalizing in decision-making processes

For live streaming and videos of the plenaries go to:

Either the conference website http://www.hiainternationalconference.org

Or directly at: http://si.easp.es/eis2011/

Carlos Artundo HIA'11 Chairperson and
General Director of the Andalusian School of Public Health
welcomes delegates to the second day

The morning's plenary speakers getting ready to speak
(and setting up their head mics, 

which have worked very well and look cool too)

Alain Poirier, Canada

HIA developed from Ottawa Charter. 1980's HIA through EIA and in the 1990s Institutionalisation of HIA centrally.

Public health 2001, Minister  can provide advise to other departments on public health and shall be consulted in relation to the development of the measures...

Strategy to implement the Public Health Act
www.msss.gouv.qc.ca/article54

1. Intergovernmental working - dialogue and discussion during the development of policy (though in some cases consultation happens at the end). Development of tools with other ministries: establishment of network of ministerial representatives, practical guide, ...


Findings
a) Greater awareness and increasing integration of HIA process
b) Request for projects other than bills and regulations e.g action plans
c) ...


2. Development and transfer of knowledge - funded research on public policy conducive to health ( meet needs of intersectoral partners, synthesise existing evidence) and evaluate public policy

Challenges and pespectives
Support changes in practice for greater use of HIA, develop strategic monitoring, strengthen intersectoral action. 20% of policies advice not taken but 80% where it was.


Rajiv Bhatia, USA

10 year story of HIA in the USA.

Improving health and getting health considered in all sectors - public, private, civil. Where does HIA fit with this intersectoral action

Started with Living Wage Bill and looked at and didn;t realise until someone working internationally said that what we had done was a HIA!

Completed 18 HIAs - labor laws, land use plans, housing, transport, ...

Findings: change public understanding of health determinants, some influence on policy, developed methodological capacity t engage with other sectors, developed accountability of EIA in relation to health, enhanced intersectoral cooperation, NGO understanding of the strategic role of health evidence and identification of policy gaps.

Moved from heavy investment in HIA (90%) to a more wider intersectoral approaches (as mentioned above).

Also developed health indicators for development projects e.g. transportation.

Leading on cross-cutting issues that has no one has current responsibility allowing/enabling the Public Health Department to take the lead/responsibility e.g. pedestrian safety - used EIA to introduce mitigation, then established a citywide law and then...

Work with most city agencies and for some created new institutions and took on policy leadership.

Lessons:
HIA is a learning process - when learning done you don't need to do it.
HIA contributed to staff capacity, methods, policy gaps, accountability, organizational relationships.
...

We started with where people are at and tried to positively participate and add value to the process.

Need for HIA in land use and transportation will disappear as we move upstream.

Role of HIA:
Poorly understood health effects
Specific analytical issue raised by policymakers
...

Need guidelines and standards of practice, technical capacity, resource commitment, cross sector experience, understanding and buy-in, publicly sanctioned screening and selection process, prioritize key issues 3-4 on which to do a HIA and then legal framework...

Need a public health political constituency to progress HiAP. Public health professionals need to take the lead even when we don't feel confident.


Laetitia Kuijpers

"Link and pin" between ministries of health and other ministries.

Similar to other countries in that health needs to raise awareness and the importance of other ministries in improving health.

"Health nearby: health care and safe facilities" - new approach is that health should go back to the people and come from people.

Make health fun!

Big socio-economic inequalities and Ministry has chosen some key districts to target in terms of 4 topics - socio-economic disadvantage, problems in the living environment as experienced by inhabitants, low quality housing stock, physical problems in the living environment according to inhabitants. But no health indicators initially.

Focus on 5 topics: housing, employment, education, integration...

Partnership between local (18 municipalities) and national government (12 ministries) and housing corporations (70) and residents of the 40 districts (5,000-200,000 population) and national alliance of private parties.

Vouchers for inhabitants (grants for community projects) alongside money to local government and the housing corporations.

National government as catalyst, 'unblocker' and mediator.

Residents have a say on the charters between institutions and action plans.

Analysis of this approach is being done through the URBAN40 project.

Municipalities doing things their own way but sharing practice is an important issue across the municipalities.

Early findings:
Employment and education results improving.

Long term involvement necessary (10 years plus, charters have helped to ensure that even though new government less interested they have carried on with the projects)
Sharing knowledge and experiences
...

Follow the flow
Knock on the door
Invest in other policies (why and how we can help each other)
Show facts and figures on health
Ask other policies to help
Join other policies and ask how to help


Taru Koivisto

HiAP complementary to public health measures and health care.

HiAP evolution:
Health for all
Intesectoral action for health
Healthy public policies
Social determinants of health
Health in all policies

Legal basis - health promotion (Constitution), public health act (very soon) and health care act

Policies - Public health programmes and national action plan

Recommendation - Quality recommendation for health promotion (2006) i.e. how it should be implemented.

HIA - a tool for HiAP, described as Human Impact Assessment to incorporate health and social issues.

Intersectoral actions - consultations/public hearings, horizontal committees with legal mandate (Public Health Committee), ad hoc committees, public health reporting (legal basis and/or cooperation of other sectors), formal communication between sectors (bilateral meetings with key civil servants/bureaucrats and impact assessment (integrated/health).

Lessons:
Similar to previous speakers - long term commitment and vision, public health expertise for advocacy, data on health determinants and analyses of links between health outcomes, determinants and policies; health literacy among public, policymakers and civil servants in all sectors and intersectoral structures, processes and mechanisms.

New health care act will incorporate public health and HiAP (stronger permanent structures for health promotion in municipalities, most already do it and this is to incorporate those that are not doing it).

 Municipalities to promote health and wellbeing. Human impact assessment is included in the new Act and the requirement for health and social care institutions to be involved in impact assessment and intersectoral working in municipalities. Also required to monitor through online system. Integrated into the traditional functions of municipalities.

HIA support: regional seminars with workshops and guidance materials, National Institute for health and welfare, model for prospective impact assessment (rapid HIA, conventional HIA), HIA developed as part of structures for health promotion, Capacity building to develop regional experts in polytechnics/universities to support municipalities.

Views from the Parador, visit to Al Hambra and the Conference Dinner

Double click to see the images in a bigger size. I'm aiming to put more pictures up on the IOM Flickr site. 

Fabulous place + Fabulous people = Fabulous evening

11th HIA Conference - Pre-conference workshop and 'networking' photos

Yes, I really was networking and learning! A really lovely day and the Andalusian School and Granada are very cool (as I'm sure you'll agree).

Dynamo workshop

Morning coffee break

Quantitative afternoon workshop I

Quantitative afternoon workshop II

Afternoon coffee break

Quantitative afternoon workshop IV

Heading out for an evening out

 At the Plaza Nueva

Paseo del Padre Manjon view up to Al Hambra

Tapas and drinks at the Paseo del Padre Manjon

Night view of the Al Hambra

3rd plenary - Gareth Williams, Wales; Nicole Valentine, Switzerland; Sarah Simpson, Italy; Stephen Linter, United States

Health inequalities, social justice and HIA

"...Things fall apart, the centre cannot hold
Mere anarchy is loosed upon the world
...
The best lack all conviction,
while the worst have passionate intensity..."

HIA is about dialogue between different stakeholders and engaging with different values

Conceptual framework for social determinants of health - which theory is the basis of a tool for HIA

SDH is based on theories of "social production of disease"

Policies on determinants of health do not necessarily tackle determinants of health inequalities

Root causes of health inequalities - systematic unequal distribution of power (social, political, economic) i.e. social position and the exposures this generates

Distal/Structural determinants = policies (more difficult to implement socially and politically)
Intermediate determinants = material resources, ...

Need broad commitment to the SDH model.

Need to strengthen health governance to address the SDH and related health inequities - lessons from Europe

Most social and global problems are 'wicked problems' difficult to tame.

Role of governance in enhancing equity and improving health - how governments and other organisations interact, relate to citizens and decide.

Adelaide Statement on Health in All Policies (HiAP) - shared governance for health and wellbeing.

HIA is a key approach in HiAP

Key pieces of WHO work:
1. Setting the political agenda to tackle health inequity in Norway, Slovenia and Scotland (published soon).
2. Online knowledge base on health system actions to tackle social determined health inequalities
3. Synthesis document

Lessons:
1. Analyse context
2. A tool to assess and strengthen governance capacity
3. Know the different levels of governance - cooperation (joint working group), coordination (advisory board to a government department, have resources), integrated policies (joint new policies)

We need to be specific about what level health inequalities is being tackled in relation to horizontal governance.

Challenge of managing crises in a rapidly changing world

Big issues for the World Bank
Economic
Food
Climate

Strategic assessments are an important part of work

Protecting pro-poor health services during financial crisis - real spending can decline, weak fiscal policies mean these are cut first, reduce overseas assistance from higher income countries

Effective interventions - broad strategies, targeted interventions and social safety net

Cost of Environmental Degradation, new book on economic impacts of adverse environmental change. Case studies e.g. 18% of impacts are on health in Tunisia.


What we need to do:
Integration
Innovation
Implementation

Adapt to changing circumstances. Interaction with affected communities is important.

2nd Plenary - Official Opening - Jesus Fernandez, DHM, Basque Government & Enrique Cruz, DHM, Andalusian Government

Impressed with the range and quality of the workshops going on during the conference. Commend the HIA conference organisers and the Andalusian School.

Important time for public health in Europe and globally both in terms of the economic crisis and natural disasters e.g. in Japan.

Window of opportunity to develop new approaches and better lik health and sustainability and for health systems to think about health in all policies.

Make health systems more cohesive and reduce inequalities and improve all people's health, a democratic and healthy society.

Good health is good for investment, human capital, entrepreneur, social development and part of the democratic fabric. Developing a new approach that looks to involve citizens in developing policy. New public health legislation and the use of HIA in policy-making in Andalusia.

1st Plenary Speaker - Adela Cortina "Yes, We Can"

This conference should be built on rock (echoing Obama campaign slogan and his speech at Georgetown).

Corporate Social Responsibility - seen as a cosmetic or philanthropy instead should be seen as a management tool, an element for prudence and an element for justice. Change the mindset of the core management of private enterprise.

Co-operation - Need to generate more friends than enemies, worst thing we can do is create more enemies and conflict e.g. engage with economists and business.

Dignity of people - Seeing people as ends and not means, as full of dignity and valuable in themselves. They have their own interests that need to be acknowledged. They are not commodities and should not be treated as such.

Commitment - To train public health professionals as citizens, what is the difference between professionals and technicians, who has ideals and is integrated into society - to prevent what we cannot cure and help promote peace. A global citizen professional.

Values - All human activities involve values and morals, about creating the good society, a safer and better world, even when it is denied they are there.

Adela Cortina is a professor at the Department of Moral and Political Law Philosophy at Valencia University and Etnor Foundation, Spain.

11th HIA Conference - Live Streaming

Hi Folks, 

I thought I'd try some fairly live blogging at the conference (the beauty of free wifi, thanks to the Andalusian School of Public Health).


You can access it through the conference website http://www.hiainternationalconference.org


Or directly at: http://si.easp.es/eis2011/



The videos of all plenary sessions will be available to watch online a few days after the conference. Please, feel free to disseminate this information among your colleagues and networks.


Courtesy of Ana Rivadeneyra, Conference Secretariat