Developing integrated approaches in Impact Assessment – NRW perspectives

1. XIth HIA conf, Granada, 14-15 April 2011 Developing integrated approaches in Impact Assessment– NRW perspectives Institute for Health and Work North Rhine-Westphalia, LIGA.NRWWHO Collaborating Center for Regional Health Policy & Public Healthrainer.fehr@liga.nrw.de

2. State of NRW: Pop 17.8 mill • LIGA.NRW, incl.Department of Prevention and Innovation; legal basis: Public Health Service Act NRW • WHO Collaborating Center for Regional(i.e. subnational)Health Policy and Public Health • LIGA.NRW Overall goal: Promoting health, reducing BoD • Mission in practice: to inform policy-making at regional (subnational) and local level, with NRW = constituency

3. State of NRW: Pop 17.8 mill, BoD p.a.~ 2.2 mill DALYs • LIGA.NRW, incl.Department of Prevention and Innovation; legal basis: Public Health Service Act NRW • WHO Collaborating Center for Regional(i.e. subnational)Health Policy and Public Health • LIGA.NRW Overall goal: Promoting health, reducing BoD • Mission in practice: to inform policy-making at regional (subnational) and local level, with NRW = constituency

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

5. „Regional health policy“ work examples • Supporting and informing (local, regional) health policy-makers, health departments, health conferences • Supporting the preparation, implementation, evaluation of (local, regional) health targets • Providing basic information on health status (BoD) / H det‘s / H conseq‘s • Analysing trends, gaps; forecasting • Estimating H needs, prevention potentials, policy impacts • Evaluations

6. Policy HIA (partial) examples • Topics (LIGA.NRW): • Drinking water privatization (Bull. WHO) • European Employment Strategy (EES) (EPHIA project) • Regional Land Use Planning in the Ruhr area • NRW Housing Subsidy Program / Wohnraumförderungs-programm (RAPID project) (cf. HIA Granada conf.)

7. „Health is the issue“ • An insight gained from Regional health policy work: • For different target groups, HIA is not necessarily the concept of interest. Instead: • For society: Health is the issue • For policy-making: Health impact is (or may be) the issue • For expert community: How to estimate the health impact is the issue (HIA)

8. „Integration“ • In this multi-layered HIA context, we need to consider „integration”for several reasons, incl. • (professional) credibility • (practical) feasibility • (intellectual) parsimony • (monetary) efficiency • ... • However, drawbacks of (and obstacles to) integration also need to be considered • One approach to systematically explore avenues to integration in HIA context: „Semantic triangle“, aka „What is in the term?“

9. H-I-A: Systematic approach„What is in the term?“

10. H-I-A: elementary components

11. H-I-A: „Semantic triangle“

12. H-I-A: „Semantic triangle“

13. Integr‘ avenue I: „Health impact“ • Health impact: • Impact on health: • range of health determinants: physical and socio-economic environment, behavioral, etc. • need to integrate into „unified“ approach • for health impact quantification: vision of a synthesis of DYNAMO HIA and INTARESE/HEIMTSA approach • Impact of health: • on health (care) system = HSIA • HI may be the key interest in other sectors, e.g. education, employment • -> challenge to try and be (more) „complete“ conc. HI

14. Approach via cross-project integration • Selected EC co-funded HIA projects: • PHASE • EPHIA • HIA-NMAC • INTARESE / HEIMTSA • DYNAMO-HIA • RAPID • EU SF • ...

15. Approach via cross-project integration • Selected EC co-funded HIA projects: • PHASE [Healthy Cities etc.] • EPHIA [incl. EU policy HIA guide] • HIA-NMAC [incl. range of HIA examples] • INTARESE / HEIMTSA „Flagship“ projects • DYNAMO-HIA of HI quantification • RAPID [Risk Assessment „2.0“] • EU SF [Structural Funds] • ... }

16. Approach via Cross-project integration • Selected EC co-funded HIA projects: • PHASE [Healthy Cities etc.] • EPHIA [EU policy HIA guide] • HIA-NMAC [incl. sample HIAs] • INTARESE / HEIMTSA „Flagship“ projects • DYNAMO-HIA of HI quantification • RAPID [Risk Assessment 2.0] • EU SF [Structural Funds] • ... • -> Do we exploit our R&D projects on HIA adequately? • Do we integrate the results into HIA practice? }

17. Approach via health impact quantification • Range of models in existence (PREVENT, ICT, MicMac...) • Potentially relevant for HIA • Tradition of being developed separately, with interaction limited or absent • Vision: towardscross-model debate / possibly cross-model integration

18. HIQ workshops: • Düsseldorf 2010 – Invitational expert workshop (report) • Granada 2011 – Pre-conference composite workshop

19. 1st HIQ workshop, Düsseldorf 2010 • Selected results: • HIQ models could help to reach a new and improved quality of science-policy interaction • But: may give an unwarranted patina of robust science • HI modeling exists in both the Environmental Health arena and the general Public Health arena. Up to now, there is little cross-project debate; and mostly separated along this divide • So far, little evidence exists concerning: • the demand of HIQ expressed by decision-makers • on the satisfaction of these groups with HIQ results provided to them • and on the eventual usefulness of the approach

20. 2nd HIQ workshop, Granada, 13 April 2011 • Composite workshop: 2 „technical“ sessions (c. 25 partic. each), afternoon „debating“ session (c. 50 partic.) • Objective: exchanging information; promoting discussion • Key HIQ questions: Why? For whom? What to quantify? How? What scale level? etc. • HEIMTSA/INTARESE, DYNAMO HIA = current „flagship projects“; other proj‘s & models also relevant; e.g. RAPID, producing new insights • Users of HI quantifications: policy-makers, persons working in policy-making environments, citizens, health professionals incl. researchers, health administrators • HIA/HIQ appreciation in policy arena: depends on multiple factors, existing examples how interest can grow • „Health policy literacy“ = a (major) challenge • --->

21. 2nd HIQ workshop, ctd. • Technical HIQ questions incl. data availiability; reliability; un-certainty; results presentation • Too early to evaluate HIQ, but HIQ widely seen as adding value to HIA • Next steps: to compile, and review, a set of practical examples of HIQ; and explore in detail how HIQ fits into the overall HIA • Since the „real“ goal is increasing health: possibly the process of HIQ turns out to be just as important as the numerical results.

22. H-I-A: „Semantic triangle“

23. (Integr‘ avenue II: „Health assessments“) • Multitude of health assessments, incl. • Health status, (indicator-based) health reporting • Health trends, forecasts • Health needs, prevention potentials • HIA (prospective, ex ante) • Health Technology Assessment • Cost-benefit • Evaluation • ... • Approach: To develop HIA as one health assessmentamong others, identifying its specific position and interrelations[Work in progress]

24. H-I-A: „Semantic triangle“

25. Integr‘ avenue III: „Family“ of h‘-related IAs Internationally, a host of Impact Assessments (IAs) emerged, many of them at least partially related to human health An initiative was started in 2009 to scientifically and practically deal with this “family“ of IAs, especially in order to harness the potential mutual benefits and to avoid the pitfall of unwel-come interference between them Discussions: • HIA09, Rotterdam (NL), with “World cafe” workshop • EUPHA 2009, Lodz (PL) • German Epidemiologic Association (DG Epi) 2010, Charité Berlin (DE)

26. Example of „family“ approach • H in SEA guidelines • Wealth of SEA guidelines: 41 guideline doc‘s, 12 online guidance webpages • Health mentioned in almost all the guidelines • Only few guidelines indicate how to assess health; whom to consult with; when to include health experts • Guidelines related to EU SEA directive: focussing on biophysical det‘s, not socio-economic det‘s of health • J. Nowacki et al. (2011): Health in SEA guidelines. HIA Conf. Granada, 14-15 April 2011

27. Other strand of „family“ approach

28. Crude typology for „integration“ • Option A: No integration, Pro: Requires no “extra” effort; strengths of existing IAs are maintained. Con: Risk of duplication of efforts; risk of confusing stakeholders; risk of producing contradictory input into decision-making and other policy contexts which could then contribute to “IA fatigue” • Option B: “Partial” integration, e.g. where EIA or SEA is being performed, integrate “health” into it, Pro: Opportunity to involve stakeholders comprehensively and efficiently; results might be more easily communicated to decision-makers. Con: Difficult to establish “equal footing” of topics, disciplines • Option C: “Full” integration, cf. EC “integrated approach”, Pro: Is “natural” approach since overall (not sectoral) impact is needed for policy-making; easiest to handle for stakeholders. Con: Requires all-round expertise; may be extremely demanding; alternatively, could fall way behind its potential. Existing IA cultures could go extinct without being adequately replaced

29. Conclusions / Rec‘s on „Family“ • Although the list of IAs for which names have been coined is long (and growing), a smaller number of IAs is supported by specific “cultures“, e.g. political support; legacy of experience • Each of the major IAs has features potentially inspiring for the further development of HIA • Recommendations: • Continue exchange of information within the “family” • In HIA information hubs (cf. books currently being prepared; gate-ways), include chapters on various (health-related) IAs • Establish ongoing discussion on “family” within emerging HIA development efforts in professional associations, e.g. EUPHA

30. Overall conclusions • Concerning HIA, „health“ is the issue for society; „health impact“for policy-making; HIA for the PH community • Multitude of „integrative avenidas“ can be derived, e.g., from H-I-A semantic triangle, incl. „HI“, „HAs“, „IAs“ • Several integrative approaches are readily available, e.g. „Family of IAs“ • Seems indispensable to „think“ integration, to be aware of the contexts, especially: complexity of HI; range of HAs other than HIA; IA cultures beyond HIA • Neither always feasible nor desirable to „do“ integration; needs critical debate and evaluation

31. Lookout • From (Regional) Health Policy perspective: HIA = a strategic topic, deserving ongoing attention, exchange of information, critical discussion • If EC and WHO integrate HIA (+/- systematically and compre-hensively) to their own policy-making, e.g. emerging „Health 2020“ program -> strong signal for HIA • „Integration“ a candidate topic for future HIA conferences and HIQ workshops