Health Equity Impact Assessment Project Report · HEIA scoping project Introduction 2 example, HEIA...

Health Equity Impact Assessment Project Report

End of grant report to LivHIR Institute – July 2010

Sue Povall, Fiona Haigh, Debbie Abrahams, Alex Scott-SamuelIMPACT, University of Liverpool

IMPACT–InternationalHealthImpactAssessmentConsortium,UniversityofLiverpool,+44‐151‐794‐[email protected]

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TheLiverpoolStatement

Equityinhealthimpactassessment

AsummaryofthekeymessagesfromtheHealthEquityImpactAssessmentPilotProject

ClosingtheGapThepublicationofClosingtheGapinaGeneration:HealthEquityThroughActionontheSocialDeterminantsofHealth(WHO,2008)‐thefinalreportoftheCommissiononSocialDeterminantsofHealth‐createdanewmomentumfortheapplicationofwhatthereporttermedhealthequityimpactassessmentthroughouttheworldandinallareasofpublicpolicywhichaffecthealthequity.TheHealthEquityImpactAssessmentPilotProjectcomprisedascopingreviewofpublishedreports,aseriesofinterviewswithglobalstakeholdersandaninternationalworkshopinLiverpool,includingparticipantsfromfivecontinents.Adetailedreadingoftheproject'simmenselyrichfindingsisstronglyrecommended.

EquityandHIAThereisnoneedforanewformofhealthimpactassessment(HIA)toaddresspolicyimpactsonhealthequity.EquitycanbeassessedwithinHIAasitcurrentlyexists‐buttheequityfocusneedsstrengtheningtoengagewiththemultipleandcomplexinfluencesonhealthequity.Thereisamultidimensionalwebofcausalinteractionsaffectinghealthequity,atallgeographiclevelsfromglobaltolocalandatallcausallevelsfromrootcausestoimmediatecauses.Withineachoftheseinteractionsthereisamoralandethicaldimension–therighttohealth.Accordingly,distributionalimpactsshouldbeidentifiedandemphasisedinallHIAs,equityshouldbeconsideredatallstagesofHIA,andfairnessandsocialjusticeshouldunderpinallHIAs.

Equityiscontextual:itsmaterial,socialandculturalpatterningvariesindifferentpartsoftheworld.PublicpoliciesandHIArecommendationsmustbesensitivetothesepatternsandtothesocialandthepolicydynamicsthatcreatethem,iftheyaretobeeffectiveinremedyinginequities.AndwhilethebasicconceptofHIAisuniversal,itsinterpretationissimilarlycontextdependent.

AdequatelyaddressingequityinHIAwillrequiretime;resources;effectivecommunication;commitmentfrompoliticalandotherkeydecisionmakers;inter‐sectoralcollaboration;widespreadinvolvementofcivilsociety;andameaningfulcommitmenttoeffectiveimplementation,monitoringandevaluationofequityrecommendations.

MakingithappenThereneedstoberecognitionthatpolicyatalllevelsimpactsonpeople'slivesandthatinequitiesthatarenotaddressednowwillcauseorcompoundfurtherinequitiesinthefuture.TheHIAcommunityneedstoadvocateactivelyforequity,inorderthatpeopleinothersectorswillunderstandtheneedtoincludeitinpolicyandinimpactassessment.Thismustincludelearningtouseavailableevidencetodistributehealthbenefitsofpolicymoreequally.

IMPACT–InternationalHealthImpactAssessmentConsortium,UniversityofLiverpool,+44‐151‐794‐[email protected]

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ExistingHIAmethodologyisappropriateinprinciplebutrequiresstrengtheningtoaddressmoreeffectivelythefullrangeofequityinfluencesandpolicyimpacts.Thesemustincluderootcausesofhealthinequitieslikeunequaldistributionsofpower,moneyandstatus,andprotectivefactorslikeresilienceandothercommunityassets.Historicalanalysiswilloftenbehelpfulinilluminatingcurrentinequities.

OtherkeyresearchareastoenhanceconsiderationofequityinHIAincludemappingofcausalnetworksrelatingtopolicyimpactsandofkeyactorsinthegenerationof(in)equitablepublicpolicies.Sourcesoffundingforsuchresearchwillalsobeakeyissue.

PilotstudiestostrengthenandteststrengthenedHIAmethodsandprocesseswillbeessential.TheseshouldfocusonurgentandimportantinequitiesthathavenotreceivedadequateconsiderationfromHIA,suchasclimatechange,healthcarecharges,tradepolicies,armedconflictandlendingconditionalities.Bearinginmindtheuniversalnatureofthe'new'determinantsneedingtobeaddressed(likeunequalpowerdistributions,whichcausehealthinequitieswithinvillagesaswellasacrosscontinents),studiesshouldfocusonallrelevantlevelsfromlocaltoglobal.Actionisrequiredworldwide–intheGlobalSouthwheretheburdenofavoidableinequityisgreatestandintheGlobalNorthwhereavoidableinequitysooftenoriginates.

ResearchwillalsobeneededonrelationshipsbetweenHIAandtheequitypolicyprocess.Thisshouldincludeconsiderationofwhatfacilitatesandconstrainsactiononequityatkeypointsinthecausalweb;howdecisionmakersatsuchpointsunderstandandusethelanguagearoundequity;ethnographicstudiesoflocalprocessesofequitypolicyimplementation,includingengagementwithcivilsociety.

Don'twait–justdoit!Takeglobalaction:PromoteaglobalconversationaboutequityinHIA–includingcivilsocietyandthemedia

Createaglobalnetwork:UsetheconversationtocreateaglobalnetworkonequityandHIA

Developandfundaglobalstrategy:Developaglobalstrategywithinthenetworktotakeactionforward.Seekcollaborativefundingformethodologicaldevelopments,researchandcapacitybuilding.

Spreadtheword:ThesemessagesshouldbedisseminatedbyWHOandotherkeyplayersgloballyandregionally.

SuePovallFionaHaighDebbieAbrahamsAlexScott‐Samuel

Researchteam,HealthEquityImpactAssessmentPilotProject

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Acknowledgements

This report is the work of IMPACT, the International Health Impact Assessment Consortium,UniversityofLiverpool.

This scoping study has been funded by Liverpool Health Inequalities Research Institute, acollaboration between The University of Liverpool and Liverpool Primary Care Trust, working toreducehealthinequalitiesintheLiverpoolcityregion.

Intotal,29peopletookpartinourinterviewsandtheLiverpoolworkshop.Afurther20tookpartintheHIA09workshopinRotterdam.Wewouldverymuchliketothankeachofthesekeyinformantsfor giving their time and sharing their knowledge and experience with us, especially those indifferenttimezoneswhomadetimeearlyorlateintheirdaystospeakwithus.

WewouldalsoliketothankthemembersofourAdvisoryGroupwhoseinputwasinvaluableinthemanagementanddesignofthisscopingstudy:RuthBarnes,CarlosDora,MarkExworthy,PaulaGrey,MaryMahoneyandSarahSimpson.

ThankyoutoFranBailey,AnneDawsonandChrisMcLoughlinfortheiradministrativesupport.

ThankyoutootoHilaryDreavesforsharinghernotesfromtheRotterdamworkshop.

IMPACTDivisionofPublicHealthUniversityofLiverpoolWhelanBuildingLiverpoolL693GB

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TableofContents

TheLiverpoolStatement ........................................................................................................................ii

Acknowledgements ...............................................................................................................................iv

1:Introduction...................................................................................................................................... 1

2:Methodology .................................................................................................................................... 4

3:ScopingReview ................................................................................................................................. 8

4:Interviews ....................................................................................................................................... 27

5:Workshops...................................................................................................................................... 39

6:Discussion ....................................................................................................................................... 52

7:Conclusion ...................................................................................................................................... 57

8:References ...................................................................................................................................... 59

AppendixA:HEIAStakeholderMapping............................................................................................. 64

AppendixB:HEIAScopingreview–literaturesearches ..................................................................... 65

AppendixC:HEIAInterviewSchedule ................................................................................................ 66

AppendixD:HEIAWorkshopProgramme .......................................................................................... 68

HEIA scoping project Introduction

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1:Introduction

InAugust 2008 theWHOCommissionon SocialDeterminantsofHealth (CSDH)published its finalreportClosingthegap inageneration:Healthequitythroughactiononthesocialdeterminantsofhealth(CSDH,2008).Thereportmadetheinstitutionalisationofwhatitcalledhealthequityimpactassessment (HEIA) one of itsmain recommendations, calling for HEIA of “all government policiesincludingfinance”.Inaddition,thecommissionspecificallyrecommended:

• investmentinHEIAtraining,toolsandresources;• thecreationofnationalandregionalsupportcentres;• ensuringbudgetingforHEIAacrossdepartments.

Earlier,inJune2009,theUKGovernmenthadcalledforhealthimpactassessment(HIA)tobeused“moresystematicallyandconsistentlytoreducehealthinequalities”andforthehealthinequalitieselement of HIA to be strengthened (DH, 2008b). This requirement has recently been furtheremphasisedbythereportofSirMichaelMarmot'sStrategicReviewofHealthInequalitiesPost‐2010(Marmot,2010)inFebruary2010.

HIA is “based on a broad model of health, which proposes that economic, political, social,psychological,andenvironmentalfactorsdeterminepopulationhealth”(O’KeefeandScott‐Samuel,2006). By identifying potential health impacts and providing evidence‐based recommendations tomaximisepositiveimpactsaswellasminimiseand/ormitigatenegativehealthimpacts,HIAenablesdecisionmakers to createhealthierpublicpolicies,programmesandprojects. Although themostcommonlyappliedHIAdefinitionhasanexplicit focusondifferential impacts, theextent towhichequity is incorporated intoHIAmethodology is variable and evidence suggests that amajority ofHIAs do not move beyond this to identify whether these differential impacts are inequitable(avoidableandunfair)(Simpsonetal,2005).

TherehaspreviouslybeenactiontostrengthentheequitycomponentofHIA.Forexample,in2000,following the recommendations of the Independent Inquiry into Inequalities in Health (Acheson)Reportemphasisingtheimportanceof'healthinequalitiesimpactassessment'(Acheson,1998),oneof the authors (ASS) obtainedDepartmentofHealth (DH) funding for an international seminar tobringtogetherkeythinkersintheareasofHIAandinequalitiesinordertoexploresomeoftheissuesaroundtherelationshipbetweenequityandHIA(DouglasandScott‐Samuel,2001).Morerecently,an Australian / New Zealand collaboration developed an equity focused HIA framework whichconcentratedondevelopingtheHIAprocesstohelppractitionerstoconsiderequity(Simpsonetal,2005). However further work is required, especially in the context of the CSDH report which isgeneratinginternationaldemandforHEIAmethodsfocusingonequityinthecontextofglobalpublicpolicy.

Inaddition,standardHIAtoolstendtofocusonprojectlevelassessmentandfailtoacknowledgetheimportance of themacro policy environment (‘the causes of the causes’). There is currently noimpactassessmentmethodologyavailablethatsystematicallyaddressesmacro/structuralimpactson health inequalities (e.g. impacts of macroeconomic policy). Nor does most current HIAmethodologyconsider impactsbeyondnationalborders.AdequateHEIAmethodologywill capturesuch influences on health equity, including those of the political and policy context. A corecomponent of HEIA is thus the consideration of such ‘upstream’ determinants of health. For


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example, HEIA should involve moving beyond identifying how a policy, programme or projectimpacts on people living in sub‐standard housing to examining how public policies are causingpeople to live in sub‐standard housing, i.e. moving beyond identifying vulnerable groups toidentifyingwhythosegroupsarevulnerableandformulatingappropriatepolicyresponses.

HealthEquityImpactAssessmentPilotProject

Oneoftheauthors(ASS)obtainedfundingfromtheLiverpoolHealthInequalitiesResearchInstitute(LivHIR) for a 12 month study to scope the requirements for Health Equity Impact Assessment.LivHIR is a collaboration between The University of Liverpool and Liverpool Primary Care Trust,working to reduce health inequalities in the Liverpool city region. The pilot project ran from 1January2009to31December2009.

Thecorecomponentsoftheprojectwereascopingliteraturereviewlookingatpeer‐reviewedandgrey literature to examine the ways in which equity is currently incorporated into impactassessment; interviewswith key stakeholders in the fields ofHIA, health equity and global publicpolicy; a stakeholder workshop in Liverpool to further develop the findings from the literaturereviewand the interviews. In addition,wewere fortunate to alsohave theopportunity to run ashortworkshop at theHIA09 conference in Rotterdam,which enabled us to explore our findingswithadifferentgroupofpeoplewithvariedHIAexperience.

Aimsandobjectives

Theoverarchingaimofthis12monthresearchprojectwastocarryoutapilotstudytodefineandtestkeyconceptsunderpinningHealthEquityImpactAssessment(HEIA).Specifically,wewantedtounderstand the extent towhich equity is already incorporated into HIA and how the impacts onequityofmacropolicycanbeconsideredwithinHIA.InparticularwewantedtoexaminewhetheranewHEIAmethodologywasneededorwhetherexistingHIAmethodologiesaresufficienttoassesspolicyimpactsonhealthequity.

Theproject'sobjectiveswereto:• Examinetheextent,rangeandnatureofresearchactivityrelatedtoHEIA;• Critically appraise existing research on equity appraisal to identify gaps in evidence and

methodology;• IdentifyandclarifykeyconceptsunderpinningHEIA;• DeveloptheoreticalandconceptualframeworksrelatingtoHEIA;• Contributetotheoreticaldebateaboutequityinhealthimpactassessment(HIA);• Demonstratethevalue/feasibilityofundertakingaprojecttodevelopHEIAfurther;• Identifyanddeveloplinkswithexperts,stakeholdersandpotentialprojectpartners;• IdentifyfunderstotargetabidtosecurefundingtodevelopHEIAbasedontheoutcomesof

thisproject.

Projectoutputs

Therearethreesetsofoutputsfromthisproject:1. Projectreports:projectreport;shortreportandchecklistforLiverpoolPrimaryCareTrust.2. Publicationsinpeerreviewedjournals:Literaturereview;HEIAprojectfindings.3. Competitivebidforsubstantivefundingtoconductresearchidentifiedinthepilotproject.


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ThefindingsfromtheresearcharepresentedinSections3to5ofthisreport. Section2describesthemethodologyused.Section6discussesthefindingsandSection7offerssomefinalconclusionsandrecommendationsfromthepilotproject.

HEIA scoping project Methodology

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2:Methodology

The aim of the HEIA pilot was to test out key concepts underpinning health equity impactassessment.Inordertoachievethisweundertookthreepiecesofinter‐relatedresearch:ascopingliterature review, interviewswithkey informantsand two internationalworkshops toexploreandaddtotheissuesarisingfromtheinterviewsandliterature.

The original intention was for these pieces of research to be undertaken sequentially, with theresults fromearlier steps informing thedevelopmentof the later ones. Unfortunately realworldresearch does not always go to plan. Our project was delayed in three ways. Firstly, themainresearcher (SP)wasboughtoutofpartof theearly stagesof theproject toworkon theMarmotReview (Marmot, 2010). This funded the involvement of FionaHaigh (FH) andDebbieAbrahams(DA). Their input has been invaluable, but did not fully cover SP’s absence from the project.Secondly,welosttimechasingrequirementsforethicalapproval.Thirdly,welosttimeattheendoftheprojectduetoillness.Asaresultofthesecomplicationsitwasdecidedtofocusonthecriticalpathof theproject– the interviewsandworkshops–and theScopingReviewwas simplifiedandconductedthroughouttheproject,althoughearlyfindingswerefedintotheworkshops.

Itwas always an intention that this projectwoulddevelop iteratively,with constant reflectiononanddevelopmentoftheprocessbasedonlearningachievedatstagesthroughouttheproject.Withhindsightwerecognise that thescopeof theprojectwas too large for the timeandresourceswehadavailable. Forthesereasons,andbecausetheprojectteammembershavenowmovedontonewprojects,thisreporthasbeendelayedbeyondtheendofthefundingperiod.

Thissectionconsiderstheoverarchingmethodologyemployedonthisproject.Thespecificmethodsusedforthescopingreview,interviewsandworkshopswillbedescribedintherelevantsections.

Projectmanagement

TheHEIApilotproject teamconsistedofAlexScott‐Samuel (PI),SuePovall,DebbieAbrahamsandFiona Haigh. We had project teammeetings approximately once every twoweeks. SP was theprimaryresearcherfortheproject;ASSandDAweretheprojectmanagers,conductedsomeoftheinterviews,werefully involved inbothworkshops,andmadecontributionstothisreport. DAalsocontributed to thescoping review. Oneithersideofhermaternity leave,FHcontributed toearlymanagement processes, drafted the NHS ethical approval application, assisted with the scopingreview,andcontributedtothisreport.

An early task in the projectwas to identify and recruit anAdvisoryGroup. Themembers of thisgroup were: Ruth Barnes, Carlos Dora, Mark Exworthy, Paula Grey, Mary Mahoney and SarahSimpson. The Advisory Group have expertise in HIA, equity focussedHIA and health equity. FHdraftedtheTermsofReferencefortheAdvisoryGroup,whichwereagreedatthefirstAGMeeting.Atthetimeofwriting,therehavebeenthreeAdvisoryGroupmeetings,twoviateleconferenceandoneface‐to‐face.

We have also submitted project reports to the funders, LivHIR, and have had two face‐to‐facemeetingswiththem.


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Projectscope

FH wrote the bid for this project and that document became the draft project outline. SomeAdvisoryGroupmembersfeltthatwewerepre‐emptingtheoutcomesofthisresearchbyaimingtotesttherequirementsfornewHEIAmethodologyandtohaveasanoutcomeofthepilotprojecttoseek funding to develop such a methodology. There was a feeling amongst the AG that HIAmethodologies already exist that can be used to assess equity impacts of policies, and that onepossible outcome of this project might, for example, be to build capacity to use these existingmethodologies. The project aims were altered to make them more open, in line with theserecommendations.

Projectmilestones

Table 1 shows the project milestones, when they were planned and when they were actuallycompleted.

Table1:ProjectMilestones

HEIAProjectMilestones PlannedDate ActualDate

HEIAAdvisoryGroupmeeting1 03Mar2009 03Mar2009

HEIAAdvisoryGroupmeeting2 Jun2009 29Jun2009

NHSethicalapproval,obtainedby 15Jun2009 N/A

Scopingreview,completedby 30Jun2009 30April2010

Mappingofkeyinformantsandstakeholders,completedby 30Jun2009 09Jul2009

Telephoneinterviews,completedby 28Aug2009 08Sep2009

HEIAAdvisoryGroupmeeting3 Sep/Oct2009 5Oct2009

HEIAstakeholderworkshopinLiverpool,completedby 30Sep2009 5&6Oct2009

Projectreports:Fullreport,shortreportandHEIAchecklistforLiverpoolPCT,completedby

27Nov2009 31May2010

HEIASteeringGroupmeeting4 Dec2009 N/A

FinalHEIAreportsdeliveredtoLiverpoolPCTby 31Dec2009 30July2010

Identifypartnersandfundersfornextphase;submitbidby 31Dec2009 ASAP

Papersforpeer‐reviewedjournal:scopingreview&fullproject,completed

31Dec2009 ASAP

Definitionsofkeyterms

Our AG recommended that we have clear definitions for key terminology used in the project,specifically health equity. SP summarised definitions from the literature for health inequalities,health inequities, health equity and HIA and produced some draft definitions. These were then


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consideredby theproject teamandAdvisoryGroup, resulting in the followingworkingdefinitionsfortheproject.

Healthinequalities/inequitiesare:“Systematic,sociallyproduced(and,therefore,avoidableormodifiable),unfairorunjustdifferencesinhealthdeterminantsorhealthoutcomesbetweengroupswithdifferentlevelsofunderlyingsocialadvantage/disadvantage.”

Healthequity:“Theabsenceofhealthinequalities/inequities.”

HealthEquityImpactAssessment:“A combination of procedures,methods and tools that systematically assesses the potential, andsometimesunintended,impactsofalocal/regional/national/globalpolicyonthedistributionofhealthorhealthdeterminantswithinadefinedpopulation. HEIAcanbeusedaspartofthepolicydevelopmentprocesstoidentifyandminimisethatpolicy’spotentialnegativeimpactsandenhanceitspotentialpositiveimpactsonhealthequity.”

Ethicalapproval

The project did not fall under the remit of the University of Liverpool ethical review committeebecause it had National Health Service (NHS) involvement; the project, therefore, needed to bereviewedbythelocalNHSNationalResearchEthicsService(NRES)committee.TheLiverpoolNRESteamconsideredtheprojectproposalandjudgedtheprojecttobeserviceevaluation,thereforenotneedingNHSethicalapproval.

Participantrecruitment

Participants in the interviews and Liverpool workshop were identified through a process ofStakeholder Mapping. FH developed a framework for the Stakeholder mapping. Here, keycategories of peoplewewouldwant to interviewwere tabulated (see Appendix A) and then theAdvisoryGroupwereaskedtorecommendindividualswithinthosegroups.Theprojectteamthenaugmented these suggestionswith suggestionsof theirown.This final listwasdiscussedamongsttheprojectteamanda listofpreferredparticipants,withreserves,wasagreedupon. Thepeopleidentifiedwerethencontactedinorderofpreferencetoseeiftheywouldbewillingtoparticipateinthe project. Attempts were made to balance the participants by gender, occupation, area ofexpertise and region within which they work. In this way the sampling was purposive (anon−random sampling method which aims to sample a group of people with a particularcharacteristic,e.g.olderpeople).Someofthepeopleinvitedtoparticipatewereidentifiedthroughother participants (snowball sampling ‐ a non−random sample method which involves an initialgroup, e.g. communityworkers, identifyingpeople they knowwith aparticular characteristic, e.g.olderpeople).Thisapproachaimedtoensurebothsystematicandwidespreadcoverage.

ThedevelopmentofafinallistofpreferredparticipantswasdoneseparatelyfortheinterviewsandLiverpoolworkshop.ThisenabledustoincludesomeoftheinterviewparticipantsintheLiverpoolworkshop, but also to broaden the range of people we could involve in the project through theworkshop.14peopletookpartintheinterviews,and19people(someofwhomwereinterviewees)tookpartintheLiverpoolworkshop;therewere29peopleintotal.


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Participants in theRotterdamworkshopwereself‐selected. Therewasonepersonwhomwehadinterviewed;otherwiseallparticipantswerenewtotheproject.

Inclusion/exclusion

Participants were included based on their expertise in equity and HIA, global public policy andhealth.TheywerepotentialHEIAusers,commissionersandpractitioners.ParticipantswerelimitedtothosewhocanspeakEnglish.WithlimitedtimeandfundstheprojectteamwouldnothavebeenabletoemploytranslatorsorinterviewersnorhaveinterviewtranscriptstranslatedintoEnglish.

Informedconsent

Participants to both the interviews and Liverpoolworkshopwere contacted through emailwith aletter informing themof thestudy,of itsaimsand theways inwhichwewould like themto takepart.Theparticipantswereassuredthattheywouldbefreetowithdrawatanytime,iftheywishedtodoso. Allparticipantswereaskedto,anddid,returna formagreeingtotakepart,givingtheirconsent to conversations being digitally recorded and their consent to the use of anonymousextractsfromprojecttranscriptsbeingusedindocumentsrelatingtotheHEIAPilotProject.

Confidentiality

Identifiable data from the project will be kept confidential unless agreed otherwise. Where thelikelihood isthatdatamaybesharedwithotherresearchers, thepotentialusestowhichthedatamightbeputmayneedtobediscussedwithresearchparticipants. Inthepresentationoffindings,detailswillbechangedwherenecessarytoensurethatanonymityismaintained(forexamplewhenusingquotes).Allidentifiablewrittenandtaperecordeddatawillbekeptinalockedcupboardinalockedroomandcomputer−baseddatawillbekeptpasswordprotectedandsecure.

Risks,burdensandbenefits

Therearenotexpectedtobeanyrisksorburdensassociatedwithbeinginvolvedinthestudy.Theinterviews and workshops did not cover sensitive, embarrassing, upsetting or personal issues.Participantswere informedof their rights to stop interviewsat any timeand the interviewswerecarriedout at a time convenient to them. Travel and accommodation costswere covered for themajority of the participants who attended the Liverpool workshop. This was an importantopportunity for participants, including potential users and commissioners of HEIA, to share theirviewsandshapeHEIAmethodology.

HEIA scoping project Literature Review

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3:ScopingReview

Introduction

The scoping review explored how equity is being addressed within HIA and related impactassessmentmethodologiesandhowthisisbeingappliedinactualassessments.Thepurposeofthiswasto:

1. IdentifywhetherequityiscurrentlybeingadequatelyaddressedwithinHIA;2. EstablishwhetherthereisaneedforaspecificHEIAmethodology;3. IdentifyissuesthatwillinfluenceaddressingequityinHIA.

ThescopingreviewbuildsontheliteraturereviewcarriedoutbyHarris‐Roxasetal(2004)aspartofthe equity focused HIA (EFHIA) project (Mahoney et al, 2004; Simpson et al, 2005). Our scopingreviewrevisitedliteraturegatheredbytheEFHIAreviewandidentifiedadditionalliteraturethathasbeenpublishedsincethen(2004‐2009).

Ingeneral,thefindingsoftheEFHIAreviewarestillapplicablein2010.Therehave,however,beensomedevelopments:

• EFHIA has provided a framework for considering equity within HIA and there are nowexamplesofEFHIAs;

• New Zealand's Health Equity Tool (HEAT) (Signal et al, 2007) also provides questionsdesigned to assist in identifying and addressing health equity impacts, and there are anumberofnewHIAguidelineswithanexplicitfocusonreducinghealthinequalities;

• ThegrowingcallsforHEIAfromtheCSDHandtheMarmotreviewintheUK(TheStrategicReviewofHealthInequalitiesinEnglandPost2010);

• WHOinterestinHEIA.

EquityfocusedHIA(EFHIA)review

TheEFHIAreviewinvolvedasearchofpublishedliterature,compilingagreyliteraturecitationindexandwebsearching.Thesearchescoveredaperiodfrom2003to2004.Atotalof42referenceswereidentified.Themainfindingswere:

• The bulk of the literature identified in this review takes the form of commentary andoriginatesfromtheUnitedKingdom.ThisreflectsnotonlyHIA’sgrowthintheUK,butalsothe statusofHIAasanemerging fieldand the impediments todisseminatingHIA findingsthatexist.

• Theliteraturereviewfoundthatequityisnoteffectivelyaddressedinotherformsofimpactassessment,withissuesofavoidabilityandfairnessrarelyexamined.

• Akeymechanismtoensuretheconsiderationofequity,citedintheHIAandgeneralimpactassessment literature, is increased community participation. This approach is based on anumberofassumptionsthatmaynotexistinreal‐worldsituations.

• HIAhasgreaterscopetoconsiderequityduetotheexplicitandimplicitmechanismsutilisedtoaddresshealthequity.Theextenttowhichthesemechanismsleadtotheconsiderationofhealth equity in practice is still very much open to question. This is largely due to theunexplainedleapthatisrequiredtomovefromidentifyingdifferentialimpactstomakingadeterminationaboutavoidability,fairnessandavenuestoaddressinequities.


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• AspecificformofHIAthataddressesequityhadnotbeendeveloped,practitionersfavouringan“equityineveryHIA”approach.Thereishoweveralackofstructuredguidanceortoolsthatmaybedrawnupontoachievethisgoalinpractice.

• Agapintheliteraturewasidentifiedforanapproachthat:o moves beyond looking at differential impacts to explicitly addressing issues of

avoidabilityandfairness,ando clarifieshowequityissuescanbeconsideredateverystepofaHIA.

• Existing approaches are limited from an EFHIA perspective because they either provideguidanceonHIAoraddressequityissues‐nonecomprehensivelyintegratebothelements.

• ManyofthosebehindtheincreasedinternationalinterestinHIAarealsopromotingahealthequityagenda,and there is increasing interest inhow the twomaybecombined.Despitesuggestions thatequityshouldbeconsidered ineveryHIAthere is littleenablingguidanceavailable.

• There is aneed,particularly in contextswhereanexplicit commitment to reducinghealthinequalitiesdoesnotexist,forclearlystructured,practicalguidanceonhowtoincorporateequityinHIA.

Methods

Ascopingreviewisaformofliteraturereviewthataimstomaptheliteraturerelatingtoaspecifictopic,andcanbeusedtoidentifygapsinexistingresearch(ArskeyandO’Malley,2005).TheaimofthisscopingreviewwastounderstandhowequityiscurrentlyconsideredinHIAandtoseewheregapsintheresearch,andinnovativepractice,are.ItbuildsuponandexpandstheliteraturereviewdonefortheEFHIAproject(Harris‐Roxasetal,2004).

Scopingreviewsareusuallyarapidappraisaloftheliteratureinaspecificarea;theylookatabroadrangeofliteratureandassuchmaycompromiseonthedepthtowhichtheyexaminethatliterature.Scopingreviewsarenotsystematicreviews,anddiffer fromsystematicreviews intwomainways:they typically answer broad research questions that are not limited to specific study designs;becauseofthis,scopingreviewstendnottobeconcernedwiththequalityofstudies,rathertheyareconcernedwithmappingthenatureandscopeoftheresearchinaparticulartopicarea(ArskeyandO’Malley,2005).

Althoughascopingreviewdoesnotemploysomeofthemethodsusedinasystematicreview,theprocessstillneedstoberigorousandtransparent.ArskeyandO’Malley(2005)suggestthefollowingfivestepstoensurethisrigour:identifyingtheresearchquestion;identifyingrelevantstudies;studyselection;chartingthedata;collating,summarisingandreportingtheresults.Theyalsorecommendconsultationwithkey stakeholders inorder to informandvalidate the findings.Early results fromthis scoping review were presented at the Liverpool workshop. Feedback on that presentationidentifiedHIAguidelinesthathadnotbeenincludedandprovidedvaluablereflectionofthescopeofthereviewatthatstage.

Reviewquestions

The purpose of this scoping review is to understand the extent and ways in which equity isconsideredwithin impactassessment. Themain focus isonequitywithinHIA;however,wewere


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alsointerestedinunderstandinghowotherimpactassessmentmethodologiesapproachedissuesofequity.Insummary:

• Howisequityaddressedwithinmethodologiesforimpactassessment?(Including:IAmethodologiesandreviewsofIAmethodologies.)

• Howisequityaddressedwithinreportsofimpactassessments:screening/scoping;assessment;reporting;recommendations;evaluation?(Including:reportsofIAsandreviewsofreportsofIAs.)

Reviewscope

There are a growing number of methodologies and tools for considering equity impacts,prospectivelyandretrospectively. This isascopingstudyto lookattherequirementsforaHealthEquityImpactAssessmentbasedonHIA;thereforetheliteraturehasbeenlimitedtothosetoolsandmethodologiesthataresimilarinscopeorstructuretoHIA.

Inparticularwesearchedpeer‐reviewedandgreyliteraturefor:• HIAmethodologieswithanexplicitequitydimension;• ReviewsofHIAmethodologies;• ReportsofHIAsthathaveexplicitlyconsideredequityintheprocessand/or

recommendations;• ReviewsofHIAswhereequityisconsidered;• Otherhealthassessmenttoolsandmethodologieswithanexplicitequitydimension.

Timeconstraintsmeantthatwewerenotabletodoanextensivesearchoftheliteratureforimpactassessments other thanHIA. The search terms for the peer‐reviewed literaturewere set so thattheywould includeother impact assessments, but the grey literature searcheswere restricted toHIA.

IntheUKthere isa legal requirementforpublicsectororganisationstoassessthe impactof theirpolicies and programmes on race, disability and gender equalities (IDeA, 2008; DH, 2008a; DH,2009).IthasbecomecommontodothisthroughasingleEqualitiesImpactAssessment(EqIA)(DH,2008a). These EqIAs may also include other categories of people that are protected fromdiscriminationbylaw.Collectivelyknownasequalitystrands,themostcommoncategoriesare:age,disability,gender,transgender,sexualorientation,raceandethnicity,religionorbelief(IDeA,2008;DH,2009).AsofOctober2009,theNationalHealthServiceEqIAincludestheaimofreducinghealthinequalitiesinEnglandbetweenpeoplefromdifferentsocio‐economicgroups(DH,2009).

EqIA have a similar methodology to HIA, but they are primarily concerned with reducingdiscrimination.Astheseimpactassessmentsarestatutoryrequirements,therearealargenumberof them. There is no overall EqIAmethodology that we can consider here as each public sectororganisationhasdevelopedguidelinesoftheirown.WedofeelitisimportanttoincludeEqIAinthereview,sowehave limitedourconsiderationtotheguidelinesdevelopedbytheNHSNorthWest,andtoreportsofEqIAsthathavebeendoneasacombinedHealthInequalitiesandEqualityImpactAssessment.

Identifyingandselectingrelevantstudies

Theliteratureincludedinthisscopingreviewhasbeenidentifiedfromvarioussources:


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1. FHsentoutrequestsfor informationto14 impactassessmentwebsitesand listservs. Thisgenerated16responsesandbroughttoourattentionfourreportsnotidentifiedfromothersources.

2. Searches for peer‐reviewed literature through the database engines Web of Knowledge(WoK), Cambridge Scientific Abstracts (CSA) and PubMed. The following databases wereselectedforsearchingonCSA:ASSIA:AppliedSocialSciencesIndexandAbstracts;BHI:BritishHumanities Index; Biological Sciences; EconLit; EIS: Digests of Environmental ImpactStatements; Environmental Sciences and Pollution Management; MEDLINE; CSA SocialServices Abstracts; CSA Sociological Abstracts; CSAWorldwide Political Science Abstracts.ThesearchesonPubMedprovedtoberedundantasbothWoKandCSAsearchesincludedMEDLINE.SearcheswerealsodonethroughGoogleScholar.

Searchcriteria:a) healthimpactassessmentAND(equit*ORinequalit*ORdisparit*)b) “impact assessment” AND (equit* OR inequit* OR inequalit* OR disparit* OR

differential*)c) (checklist OR gauge OR audit) AND (health AND (inequalit* OR differential* OR

disparit*ORequit*)d) “healthequityimpactassessment”e) “healthinequalitiesimpactassessment”f) “equitygauge”OR“equityaudit”

Recordsretrieved:These searches retrieved 988 records, 798 after duplicates had been removed. TheserecordswerethenscannedbySPand,basedonthetitleandabstractonly,thosethatmetthefollowingbasicexclusioncriteriawererejected:before1990;notinEnglish;norelevancetohealthequity(e.g.screeningforautism,hospitalaudit); inequalitiesinserviceprovision;noabstract.Thisleft88records.Tworeviewers(SPandDA)thenassessedthese88recordsfor relevance to the review, based on title and abstract only. Recordswere selected forinclusion in the review (24) where both reviewers had chosen it for inclusion. FH thenscreened and summarised these remaining 24 records based on the full‐text article; 12articleswereincludedinthereview.

3. HIA Guidelines were identified from reviews of guidelines and through personalrecommendationsandresponsestotheRsFI;10areincludedinthereview.

4. ReportsofHIAsinthegreyliteratureweresourcedthroughsearcheson:thegreyliteratureDB,OpenSigle;HIAwebsites:BenCaveAssociates,HIACommunityWiki,HIAConnect,HIAGateway,HIANetwork,HumanRightsImpactResourceCentre,IAIA,IMPACT,LondonHealthCommission, NICE, NZ HIA Support Unit, Scottish HIA Network, Welsh HIA Support Unit,WHOHIApage;referencelistsinreviewsofHIAguidelines;personalrecommendations.

Searchcriteria:a) OpenSigle:

i. (("impactassessment"OR"healthimpactassessment")AND(equityORinequityORinequitiesORinequalityORinequalitiesORequality));


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ii. “health impact assessment” OR “sustainability impact assessment” OR“integrated impact assessment” OR “socio‐economic impact assessment” OR(“environmentalimpactassessment”ANDhealth).

b) HIAGateway:i. Level=policyortype=inequalities,notMentalWell‐beingImpactAssessment,

withanactiveweblink.c) WelshHIASupportUnit:

i. Policylevel/strategies(notprojectsorprogrammes);textcontains“equal”or“equit”withsomediscussionofequityconsiderations;HIIA;HIAandHIIAguidelines.

d) Allotherwebsites:i. Fulldocuments–nosummaries;weblinkworks;textcontains“equal”or“equit”

or“disparit”withsomediscussionofequityconsiderations.

Recordsretrieved:SP hand searched the websites noted above using the search criteria as an initial selectionprocess. These searches retrieved too many papers to include in the scoping review. Forpractical reasons only, the 39 reports retrieved through searches on HIA Connect and HIAGateway were included in the data extraction stage of the review. SP then assessed eachdocumenttoensurethatitfittedtheoverallinclusioncriteria(seeAppendixB)andthathealthequity was considered explicitly within the document, either as health equity, healthinequalities,healthdisparitiesorasdifferentialimpactsonidentifiedsubgroups.TheHIAswerelimitedtothosethatwerelookingatimpactsatthepolicylevel.SomebasicqualitycriteriawerealsoappliedtothereportsofHIAs:

• Isthisareportofanimpactassessment?If‘No’thenexcludefromthereview.

• Isequityorreducinginequity/inequalitiesaprimaryaimoftheimpactassessment?If‘No’thenexcludefromthereview.

• Arethemethodsclearlydescribedandappropriatetothestatedequityaims?If‘No’thenexcludefromthereview.

• Arethefindingsrelatingtoequityclearlypresentedanddiscussedinthereport?If‘No’thenexcludefromthereview.

16reportsofHIAswereincludedinthereviewfromthesesources.

Structureofthefindings

Thefindingsfromthisreviewarepresentedinthefollowingsections:• EquityinHIAguidelines:reviewsfromtheliteratureandareviewofselectedguidelines;• EquityinHIApractice:reviewsfromtheliteratureandareviewofselectedHIAreportsand

HIAevaluations;• Equityinotherrelatedareas.

EquityinHIAguidelines

ThestandarddefinitionofHIAincludesthespecificconsiderationofdifferentialhealthimpactsandequity isacoreprincipleofHIA. Howeverexperiencehasshownthat theconsiderationofequitywithin HIA is difficult to achieve. Guidelines on addressing inequalities in HIA produced by theNationalInstituteforHealthandClinicalExcellence(NICE,2005)concludesthat


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there is a consensus that practitioners have a difficult task ahead of them to successfullyaddress inequalitieswithinHIA,and thatwithouta sufficient focuson inequalities theymaywellnotachievesuchanoutcome(NICE,2005,p.16).

However,theyalsoconcludethatitisfeasible.

ReviewsofHIAMethodologies

ThreereviewsofHIAmethodologiesareincludedinthisreview:Harris‐Roxasetal(2004),Mindelletal(2008)andOrensteinandRondeau(unpublished).Twoofthesereviews(Harris‐Roxasetal,2004;OrensteinandRondeau,unpublished)definehealthinequitiesandhealthinequalities,andmakethedistinctionthathealthinequitiesaredifferencesinhealthstatusthatareavoidableandunfair.

A summary of the findings from the Harris‐Roxas et al (2004) review, conducted for the EFHIAproject,arepresentedatthebeginningofthischapterandarethestartingpointforthisreview.TheEFHIAreviewwasascanoftheliteratureandassuchisnotcomprehensiveordoneindepth.ItdoesgiveanindicationoftheextenttowhichequityhasbeenconsideredinHIAandothermethodologiesand tools. Harris‐Roxasetal (2004) conclude thatHIA isan importantmechanism for includingaconsiderationofequityinplanningprocesses,buttheissuesarenotsystematicallyaddressed.TheyfoundthatoftenequityisinferredthroughthemodelofhealthusedintheHIAandthatevenwheredifferentialimpactsonhealthareconsideredexplicitlythesearenotdiscussedintermsofwhetherornotthesedifferencesareavoidableandunfair(Harris‐Roxasetal,2004).

Harris‐Roxas et al (2004) also examined whether or not equity was considered in other impactassessmentmethodologies.They foundthatdifferential impactsofpoliciesandprogrammeswereconsidered inapatchyway,mostly throughconsideringdifferencesbygender, ethnicityandareadisadvantage.Again,issuesofwhetherornotthesedifferencesareavoidableorunfairwererarelyconsidered(Harris‐Roxasetal,2004).

Mindell et al (2008) conducted a comprehensive review of guidelines and toolkits that gaveadequate advice for someone to carry out anHIA. Although the authors discuss the inclusion ofequityandinequalitiesinHIA,theydonotofferdefinitionsforeitheroftheseterms.Itisclearfromoneoftheirdatatables,however,thatconsiderationsofequitywithintheHIAguidelinesreviewedcanvaryfromnothing,throughtheconsiderationofthedifferentialimpactsonspecificgroups,toacommitment to reducing inequalities. Mindell et al (2008) found that all but five of the 27frameworksreviewedreferredtotheconsiderationofdifferentialhealthimpacts,andinmostcasestheseweretobeassessedbyconsideringspecificvulnerablegroups.TheyfoundthattherewasnoconsensusonwhetherthesevulnerablegroupsshouldbeidentifiedatthestartoftheHIAorduringtheHIAprocess.Theyfoundfiveframeworksofferingguidanceontheconsiderationofdifferentialexposurestoissuesraisedand/orvulnerabilitytotheirimpacts(EuropeanEPHIA;Australia’sEFHIA;Australia’s CHETRE HIA guidelines; New Zealand’s Whānau Ora HIA; Welsh Health InequalitiesImpactAssessmenttool),withtheAustralianframeworkshavingaparticularlystrongequityfocus;sixframeworksprovidedastructuredwaytoassesspotentialimpactsonequity(QueenslandHealthHIAguidance;InstituteofPublicHealthinIreland’sHIAguidance;Birmingham’sHIAResearchUnit’sHIAtrainingmanual;EuropeanEPHIA;Australia’sEFHIA;NewZealand’sWhānauOraHIA),givingatotalofeightwithanexplicitapproachtoequity,inequalitiesordifferentialoutcomes(Mindelletal,2008).


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OrensteinandRondeau(unpublished)conductedascanin2009ofHIAtoolsforaCanadianprojecttoclarifytherequirementsforHEIAinCanada.TheirsisacomprehensiveconsiderationofHIAtoolsand frameworks and other frameworks that might guide the inclusion of equity in public policydevelopmentprocessesandprojects.LikeHarris‐Roxasetal(2004),theyconcludethatHIAoffersapromising methodology for including a consideration of equity in policy development processes.MostofthetoolstheyidentifiedwereforuseinthescreeningandscopingphasesofHIA,however,andtheyobservethatHIAswithanequityfocushavenotbeenevaluatedtodeterminetheirimpactonhealth inequalities. Determiningwhat is inequitable – avoidableandunfair – requires a valuejudgementandOrensteinandRondeau(unpublished)concludethattherearenotoolstohelpjudgefairness. They recommend EFHIA from Australia, Whānau Ora HIA from New Zealand and theapproachproposedbyQuigleyetal(2005).

ReviewofselectedHIAguidelines

We identified 10 impact assessment methodologies for inclusion in this review (see Table 3.1).Thesewereselectedonthebasisthattheyhadbeenrecognisedintheliterature,orfrompersonalrecommendation, as having the explicit aim of reducing health inequalities or improving healthequity.

Table3.1 ImpactAssessmentguidelinesincludedintheHEIAscopingreview

Guideline Origin Reference

TheMerseysideGuidelines England Scott‐Samueletal(2001)

Addressinginequalitiesthroughhealthimpactassessment England Tayloretal(2003)

Improvinghealthandreducinginequalities:apracticalguidetohealthimpactassessment

Wales WHIASU(2004)

Equityfocusedhealthimpactassessmentframework(EFHIA) Australia Mahoneyetal(2004)

Europeanpolicyhealthimpactassessment(EPHIA) Europe EPHIAProjectGroup(2004)

Aguidetohealthimpactassessment:ApolicytoolforNewZealand

NewZealand PHAC(2005)

Mentalwell‐beingimpactassessment:atoolkit England Cogginsetal(2007)

WhānauOraHealthImpactAssessment NewZealand MinistryofHealth(2007)

NHSNorthWestEqualityImpactAssessmentToolkit England NHSNW(2008)

HealthImpactAssessment:Guidance Ireland Metcalfeetal(2009)

Three of these guidelines are specifically for policy level HIA (EPHIA Project Group, 2004; PHAC,2005;MinistryofHealth,2007),therestareforuseatthepolicy,programmeorprojectlevels.Allbut the EqIA (NHS NW, 2008) follow the basic steps of screening, scoping, impact identification,assessment / appraisal, reporting / recommendations, monitoring / evaluation, although theMerseysideGuidelines(Scott‐Samueletal,2001)andEPHIAguidelines(EPHIAProjectGroup,2004)followadifferentmodelwithintheassessmentphase.EqIAhasaslightlydifferentpurposeinthatitis designed to assess the impact on equalities groups – those population groups protected fromdiscriminationby law intheUK. Assuchthetargetpopulationsareclearlyarticulatedthroughout


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theframework,whichincludesthestagesofpreparation,informationgathering,assessment,reportwriting,consultationonadraftreport,publishingandmonitoring.Themajorityoftheseguidelinesprovidedetailedinstructions,promptsandtoolkitstoguidetheuserthroughtheHIAprocess.

Twooftheguidelines(Tayloretal,2003;NHSNW,2008)donotdiscusswhichmodelofhealththeyare using; all of the others use a broad model of health, encompassing social, economic andenvironmentaldeterminants. Similarly, threeguidelines (Tayloretal, 2003;Mahoneyetal, 2004;NHSNW,2008)donotdefineHIAorIA;Scott‐Samueletal(2001)defineHIAas“theestimationofthe effects of a specified action on the health of a defined population” (p.4), the remainingguidelinesalluseaversionoftheGothenburgConsensus(1999,p.4)definition:

Health Impact Assessment is a combination of procedures,methods and tools bywhich apolicy, program or project may be judged as to its potential effects on the health of apopulation,andthedistributionofthoseeffectswithinthepopulation.

Although consideration of equity or inequalities is central to all these frameworks, the equityterminology used is inconsistent. Only four of the guidelines define the equity terminology used(Tayloretal,2003;Mahoneyetal,2004;EPHIAProjectGroup,2004;Metcalfeetal,2009).Ofthese,the EPHIA ProjectGroup (2004) andMetcalfe et al (2009) use the term “health inequalities” anddefine it as “avoidable and unjust” differences in health. Mahoney et al (2004) and Taylor et al(2003)makeadistinctionbetweenhealthinequalitiesandhealthinequities,bothstatingthatthereisamoralandethicaldimension tohealth inequities– thesearehealth inequalities thatarebothavoidableandunfairorunjust(Tayloretal,2003;Mahoneyetal,2004). Tayloretal (2003)makehealthinequalitiesthefocusoftheirframework;Mahoneyetal(2004)makehealthequitythefocusoftheirs.Ofthesixguidelinesthatdonotofferadefinitionoftheirchosenequityterminology,fouruse the term health inequalities (PHAC, 2005; MWIA, 2007; Ministry of Health, 2007; NHS NW,2008). TheMerseysideGuidelines(Scott‐Samueletal,2001)usestheterm‘equity’andtheWelshguidelines(WHIASU,2004)usesthetermshealthinequalitiesandequityinterchangeably.

Giventhecontestednatureoftheterm“healthinequalities”,itisdisappointingthatsofewoftheseguidelinesareclearaboutthedefinitiontheyareusingandwhetherornottheymeantoincludethemoral and ethical dimension of assessing potential health differences in terms ofwhether or notthey are avoidable andunfair / unjust. In fact, only the EFHIA framework (Mahoney et al, 2004)offersexplicitguidanceonincludingissuesofavoidabilityandfairnessintheHIAprocess.

Within these guidelines, equity or inequalities is generally addressed through the inclusion ofstakeholders, especially those from affected communities, and the assessment of potentialdifferential impacts on population subgroups, often referred to as vulnerable or disadvantagedgroups:

• Seven frameworks (Tayloretal,2003;WHIASU,2004;Mahoneyetal,2004;EPHIAProjectGroup, 2004; PHAC, 2005; Ministry of Health, 2007; Metcalfe et al, 2009) suggest thesegroups should be identified during theHIA process.Of these, four (Mahoney et al, 2004;EPHIAProjectGroup,2004;PHAC,2005;MinistryofHealth,2007) identify subgroups thatshouldbeincludedasaminimum;

• Fiveframeworks(Scott‐Samueletal,2001;WHIASU,2004;PHAC,2005;MinistryofHealth,2007;Metcalfeetal,2009)offerguidanceonthesortsofgroupstoconsider.InthecaseoftheNewZealandguidelines,thesegroupsareeitherinadditiontotheessentialinclusionof


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Māoripopulations(PHAC,2005)orasparticularsubgroupsoftheMāoripopulationsthatarethefocusoftheHIA(MinistryofHealth,2007);

• These suggested subgroups may include characteristics such as age, gender, race,geography,socio‐economicstatus.

• Two frameworks (Coggins et al, 2007; NHS NW, 2008) have fixed groups that should beconsideredintheIA.InthecaseoftheEqIAframework(NHSNW,2008),thesegroupsaredefined by legislation and are known as the seven equalities strands ‐ age, gender, race,disability, religion, sexual orientation, trans‐gender – and are the groups protected fromdiscriminationbylaw.

• Twoframeworks(WHIASU,2004;Cogginsetal,2007)arguethatthereshouldbeabalancebetween the recommendations concerned with the impact on subgroups and thoseconcernedwiththeimpactonthepopulationasawhole.

• TheEqIA(NHSNW,2008)statesthatidentifieddifferentialimpactsshouldbeassessedastowhetherornottheyare“unjustifiable”inrelationtothepolicy’saims,andwhetherornottheyaremissinganopportunitytopromoteequality.

Within the HIA process, five frameworks (Taylor et al, 2003;Mahoney et al, 2004; EPHIA ProjectGroup,2004;PHAC,2005;MinistryofHealth,2007)stateexplicitlythatequityand/orinequalitiesshouldbeconsideredatallstagesoftheHIA.Otherwise,theguidanceintheframeworksisweightedtowardstheinclusionofequityinthescreening,scopingandappraisalstages.Onlytwoframeworks(NHSNW,2008;Metcalfeetal, 2009)donotexplicitly state thatequity shouldbea factor in therecommendations. Mahoney et al (2004) observe that the inclusion of equity and inequalitiesconsiderationsinHIArecommendationsisdifficultandislikelytobemetwithresistance.

Threeframeworks(Mahoneyetal,2004;EPHIAProjectGroup,2004;PHAC,2005)explicitlystatethevaluesthatunderpintheprocess.Twoguidelines(Mahoneyetal,2005;EPHIAProjectGroup,2004)explicitlyrecommendtheconsiderationoftheprocessesbywhichapolicyhasanimpactonhealth,healthdeterminantsorpopulationgroups.

Fromthepeer‐reviewedliterature

Lester et al (2001) describe the Health Inequality Impact Assessment (HIIA) rapid appraisalmethodologydevelopedbyBroTafHealthAuthority.HIIAisdescribedasarefinementofHIAwhichensures a focus of the needs of the most disadvantaged. This paper focuses on using HIIA forprioritisingactionstotacklehealthinequalities.Inthisexampleratherthanassessingtheimpactsonhealth inequalities the focus of the assessment is actions to tackle inequalities. Five steps aredescribedwhichrelatequitecloselytotraditionalHIA:brainstormingto identify impactsonhealthdeterminants; the local context in which identified health determinants operate is discussed;evidence collection; identifying opportunities for action, prioritisation considering strength ofevidence, magnitude of impact, probability of achieving change locally and time scale. It’sinteresting that the prioritisation criteria do not appear to be actually aimed towards addressinginequalities.

EquityinHIApractice

PublishedreviewsandreflectionofHIApractice


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Nine reviews and reflections of HIA practice have been identified: Parry and Scully (2003) offerreflectionsontheconsiderationofhealthinequalitieswithinHIA;Aldrichetal(2005)andSimpsonetal(2005)considertheuseofEFHIAinpractice;Kemm(2005)reflectsonHIApracticeinthepastandits future challenges; Quigley et al (2005) present a brief review of HIA practice as part of theirguidelinesonhowtoincorporatehealthinequalitiesinHIA;Harrisetal(2007)discussHIAinurbancontexts;Harris‐RoxasandHarris(2007)reflectontheprocessofHIAbasedonninecasestudiesofHIAsreportedinthesameissueofNSWPHBulletin;Wismaretal(2007)maptheuseofHIAacrossEurope;Dannenbergetal(2008)review27HIAsconductedintheUSAbetween1999and2007.

Most HIAs include a consideration of equity or inequalities (Quigley et al, 2005), andmost oftenthroughassessingdifferential impacts forparticularpopulation subgroups (ParryandScully,2003;Simpsonet al, 2005;Harris‐Roxas andHarris, 2007;Wismar et al, 2007;Dannenberg et al, 2008).The intentions for assessing equity often do notmanifest in practice, however (Parry and Scully,2003;Wismaretal,2007),andissuesofavoidabilityandfairnessarerarelyexamined(Simpsonetal,2005). Thereisoftenanuncriticalassumptionthatincreasedcommunityparticipationwill initselfensureanequityperspective(Simpsonetal,2005).AlthoughgenerallyHIAsusemodelscapableofaddressinghealthequity,mostdonotusea structuredapproach todoing so (Aldrichetal, 2005;Quigley et al; 2005). Harris‐Roxas and Harris (2007) note that, in the HIA case studies theyconsidered,subgroupanalysiswasoftenlimitedtotheconsiderationoftheimpactsonindigenousgroups.ParryandScully(2003)andHarris‐RoxasandHarris(2007)suggestthatHIAsshouldincludea minimum set of subgroups (such as age, gender, ethnicity, socio‐economic status), with othergroupsdefinedaspartoftheHIAprocess.

Evenwhereanassessmentofdifferentialimpactsofapolicyorprogrammehasbeendone,theHIAsoftendonotpresent their findings inawaythatdemonstrates that the impactonhealthequity/inequalitieshasbeenassessed(ParryandScully,2003;Kemm,2005;Quigleyetal,2005).Wismaretal(2007)foundthatidentifyingandreportingequityconsiderationswithintheHIAprocessrarelyledtochangesinthedecisionsmade.

Measuring equity in HIA is difficult. It is complex and resource intensive (Quigley et al, 2005;Simpsonetal,2005;Wismaretal,2007), it ischallengingmethodologicallyand istimeconsuming(Quigley et al, 2005; Simpson et al, 2005;Harris‐Roxas andHarris, 2007;Wismar et al, 2007). Inaddition it can be limited by the lack of synthesised or summarised evidence (Harris‐Roxas andHarris,2007).Throughtwocasestudies,Quigleyetal(2005)findthatincludinginequalitiesinHIAisfeasible,andtheyprovideastructurefordoingso.Simpsonetal(2005)arguethatjustcarryingoutscreeningwith anequity focus (withexplicit considerationsof avoidability and fairness)wouldbeuseful.

Harrisetal(2007)identifyreasonswhyincorporatingequityintoHIAhasproventobedifficult:• Lackofdefinitionsconcerningwhichpotentialimpactsareunfairandwhetherproponentsof

aproposalareinapositiontoinfluencetheirelimination,• LackofawarenessofwhichpopulationgroupstoconsiderinanHIA,and• Lackofavailabledatatoassesswhetherthesegroupsexperiencedifferentialimpacts.

Inaddition to this theauthorsalso identify the risk thatHIAs tend to focusononeor twohealthdeterminantsand‘forget’toconsiderthedifferentialdistributionofimpacts(Harrisetal,2007).


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Approachestodealingwiththesechallengesarealsoidentified(Harrisetal,2007):• Lack of definition on what is unfair and avoidable requires thinking through who is

responsibleforwhatactionsonwhatimpacts.• Concerningpopulationgroups,ataminimum it is recommendedthatage, socio‐economic

position, ethnicity and culture, locationdisadvantage, anddisabilityorotherhealth statusareconsidered.

• Where data are lacking, the potential for inequity should nonetheless be reported (alongwiththelackofdata).

FiveEFHIAcasestudiesarereportedbyAldrichetal (2005)andSimpsonetal (2005). Thesecasestudies demonstrated that EFHIA enabled the identification of potential unintended anti‐equityconsequencesandgenerate recommendations thatpotentiallyenhanceequity / reduce inequality(Aldrichetal,2005).TheydothisbyincorporatingspecificquestionsorprocessestoeachHIAstep.These questions and processes are intended to prompt the exploration of equity considerationswithintheHIA(Aldrichetal,2005),assessingwhetheridentifiedpotentialdifferentialhealthimpactsareavoidableandunfair(Simpsonetal,2005).Assuch,EFHIAhasthecapabilitytopreventhealthinequities by using the findings from the EFHIA to amend, ameliorate and improve the proposedpolicy,programorproject(ideallybeforeitisimplemented)(Simpsonetal,2005).

Harris‐RoxasandHarris(2007)identifywaysinwhichtheHIAprocesscanenhanceequitywithinthepolicy process:HIA canbroaden the rangeof potential health impacts that are assessed;HIA canintroduce evidence into the decision making process that would not otherwise have beenconsidered; engaging stakeholderswith theprocess canmake the recommendations fromanHIAmore acceptable and identify issues that would not otherwise have been included in the policymakingprocess;HIAmayactasacatalystforcollaborativeworkingeitherduringtheHIAprocessorasaspin‐offfromtheprocess.

HIAevaluations

MathiasandHarris‐Roxas (2009)observe thatevaluationsofHIAsare rarelydoneandevenmorerarelypublished.Therearefewevaluationsincludedinthisstudyforthatreason.InadditiontotheMathias and Harris‐Roxas process and impact evaluations of the Greater Christchurch UrbanDevelopmentStrategyHIAinNewZealand(2009),threeofthe16HIAsincludedinthereviewhavereportedthefindingsofprocessevaluations(QueenslandHealth,2003;CDHB,2006;Tugwelletal,2007). Collectively, these evaluations demonstrate that HIA can be successful in includingrepresentativesofdisadvantagedcommunities,itcanprovideaforumforsharingunderstandingandlearningtheequitylanguageofparticipatingorganisations,anditcanleadtoashiftinunderstandingabouthealth,healthinequalitiesandsocialdeterminantsofhealth.

Mathias andHarris‐Roxas (2009) found that theHIA did influence the development of theUrbanDevelopmentStrategy,butthatnotalloftherecommendationsweretakenup,andnotallofthosethat were taken up translated into action points. They also found that the HIA process had aninfluence beyond the development of that particular policy in terms of improved cross‐sectoralworkingandthegreaterparticipationofMāoriinlocalbodies.OnekeyinformantinthisevaluationfeltthathealthinequalitieshadnotbeenadequatelyconsideredintheHIA,however(MathiasandHarris‐Roxas,2009).


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Although Harris et al (2006) did not include a formal evaluation in their report of an HIA ofcomponentsoftheAustraliaBetterHealthInitiativeinNewSouthWales,theydidincludereflectionsontheprocess.TheyreportedthattheHIAprocesswasclearandtherewasgoodcollaborationandcommitmentbetweenparticipantsandpolicymakers.Intermsoflimitations,theyfoundthattherewasalackoftimetoproperlyconsidertheevidencebaseandthatsomeparticipantshaddifficultiesin stepping away from their own strategies in order to identify potential positive and negativeconsequences(Harrisetal,2006).

ReviewofselectedHIAreportsandevaluations

16HIAshavebeenincludedinthisscopingreview(seeTable3.2).Theywerechosenbecausetheyare policy level HIAs and have an explicit aimof reducing health inequalities or improving healthequity.

SevenoftheHIAsprovidedescriptions,ratherthanadefinition,perse,ofHIA(Abrahamsetal,2004;Quigley, 2005; CDHB, 2006;Quigley et al, 2006;WSROCandGethin, 2007;Abrahamset al, 2008;LHC,2008).Winters(2006)usesthedefinitionfromtheMerseysideGuidelines(Scott‐Samueletal,2001). The remaining HIAs use the Gothenburg Consensus (1999) definition of health impactassessment.

MostoftheHIAsusedtheWHOdefinitionofhealthorasocio‐environmentaldefinition.Onlytwooffered no definition at all (Quigley, 2005; LHC, 2008), although it was clear that Quigley (2005)employedasocio‐environmentalmodelandLHC(2008)acknowledgesbroaddeterminantsofhealth.TwoHIAsincorporateindigenousdefinitionsofhealth:AustralianAboriginal(TrindallandBell,2008)andMāori(Quigleyetal,2006).Bhatiaetal(2008)definehealthintermsofillness,butthisHIAisassessingtheimpactsofapolicytointroducepaidsickleaveinCalifornia;broaderdeterminantsareconsideredthroughouttheHIA.

Thetermsequity, inequitiesor inequalitiesarenotalwaysdefined.Wheretheyaredefined, threeHIAsused the term“health inequalities” in thevalue‐neutral senseofdifferences inhealth statusbetween population groups (Abrahams et al, 2008; LHC, 2008; PHDU, 2009), four used the term“healthinequalities”inthesensethatthesedifferencesmaybejudgedtobeavoidableandunfair/unjust (Chilaka, 2005; CDHB, 2006; Quigley et al, 2006; Tugwell et al, 2007), and three defined“health inequities” in thisway (QueenslandHealth, 2003; Harris et al, 2006;WSROC andGethin,2007).

Considerations of equity or inequalities are usually assessed through differential impacts onvulnerable / disadvantaged groups, specific population subgroups (such as Australian Aborigines,Māori, or the UK equalities groups), or subgroups identified during the HIA as being particularlysensitivetothe impactsof thepolicybeingassessed. TheCoffsHarbourHIA(Tugwelletal,2007)includesanassessmentmatrixwithcolumnstoassesswhetherornotidentifieddifferentialimpactsare avoidable and / or unfair. Neither this HIA nor any of the others that define inequalities orinequitiesaspotentialdifferencesinhealthimpactsthatareavoidableandunfair/unjustexplicitlydiscussthesejudgementswithinthetextofthereports. Thatisnottosaythattheseassessmentshavenot beenmade; it is clear that someof theseHIAshave considered the equity of identifieddifferencesverythoroughly(Harrisetal,2006;Quigleyetal,2006;Tugwelletal,2007;WSROCandGethin,2007).Whataremissingareexplicitdiscussionsofthevaluejudgementsmadetodetermine


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whether or not potential impacts are inequitable. Similarly, even where there is a clearconsideration of equity issues throughout the HIA process, recommendations are not alwaysexplicitlyframedinthisway.

Table3.2 HealthImpactAssessmentsincludedintheHEIAscopingreview

Reference Source TypeofHIA

Abrahamsetal(2004):PolicyHealthImpactAssessmentfortheEuropeanUnion:AHealthImpactAssessmentoftheEuropeanEmploymentStrategyacrosstheEuropeanUnion.EU.

HIAGateway EPHIA

Abrahamsetal(2008):AHealthImpactAssessmentoftheHealthisWealthCommission’s‘BigIdeas’.England.

HIAGateway Desktop

Bhatiaetal(2008):AHealthImpactAssessmentoftheCaliforniaHealthyFamilies,HealthyWorkplacesActof2008.USA.

HIAGateway Notstated

CDHB(2006):HealthImpactAssessment:GreaterChristchurchUrbanDevelopmentStrategyOptions.NewZealand.

HIAConnect Rapid

Chilaka(2005):AProspectiveandComprehensiveHealthImpactAssessmentofCreweandNantwichNeighbourhoodRenewalStrategy.England.

HIAGateway Comprehensive

CQGRD(2007):AtlantaBeltlineHealthImpactAssessment.USA. HIAConnect Comprehensive

Harrisetal(2006):RapidEquityFocusedHealthImpactAssessmentoftheAustraliaBetterHealthInitiative:AssessingtheNSWcomponentsofpriorities1and3.Australia.

HIAConnect RapidEFHIA

LHC(2008):HealthInequalitiesandEqualityImpactAssessmentof‘HealthcareforLondon:consultingthecapital’:Finalreport.England.

HIAConnectIntegratedHIIAandEqIA

QueenslandHealth(2003):AssessingtheUtilityofHIAforServiceIntegration:AssessmentoftheGoodnaServiceIntegrationProject.Australia.

HIAConnect Notstated

PHDU(2009):AhealthimpactassessmentoftheEasternCorridorproposalsinPlymouth’sEastEnd.England.


Quigley(2005):Avondale’sFutureFrameworkrapidHIA:finalreport.NewZealand.

HIAConnect Rapid

Quigleyetal(2006):TheGreaterWellingtonRegionalLandTransportStrategy:HealthImpactAssessment.NewZealand.

HIAConnect Rapid

TrindallandBell(2008):GoodforKids.GoodforLife.Equity‐FocusedHealthImpactAssessment.Australia.

HIAConnect RapidEFHIA

Tugwelletal(2007):CoffsHarbourOurLivingCitySettlementStrategy:HealthImpactAssessment2007.Australia.

HIAConnect Rapid

Winters(2006):HealthImpactAssessmentofthePatientChoiceAgenda.England.


WSROCandGethin(2007):GreaterWesternSydneyUrbanDevelopmentHealthImpactAssessment:Finalreport.Australia.

HIAConnectMainlydesk‐based

The HIAs included here demonstrate two further aspects of equity impacts. The first is theconsiderationofsocialdeterminantsofhealth(SDH).Asalreadynoted,mostoftheHIAsemploya


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socialmodelofhealthandas suchare lookingat socialdeterminants. WSROCandGethin (2007)recognise that inequities result from barriers to achieving full health potential and that, as thedeterminants are social, the solutions need to be joined‐up. Harris et al (2006) note theinterconnections between policies and two HIAs (Abrahams et al, 2004; Abrahams et al, 2008)considerthe“causesofthecauses”ofhealthinequities,whichcanbelimitedbyalackofevidence(Abrahams et al, 2008). Winters (2006) discusses the equity implications of consumerism andcompetitionwithinEnglishhealthcareorganisations.

TheGoodnaHIA (QueenslandHealth, 2003)was a pilot to test the efficacy of HIA in consideringmulti‐departmentalserviceintegrationtoaddressSDH.Ithastwofacets:anHIAofhumanserviceintegrationandtheassessmentofHIAasanappropriatemethodologyforpublichealthpractitionersto assess the impacts of human service integration. Equity ‐ ensuring themultiple and complexneeds of disadvantaged communitiesweremet ‐ was a key component of this HIA. The findingsindicated the importance of communication and relationship building between services andcommunities.Theyalsorevealedtheneedtoaddresstheunderlyingcausesofhealthinequalities.Theunexpected findings,bothpositiveandnegative,canbeusedto informfutureHIAsofserviceintegration.Thereportconcludesthat:"...[HIA]hasthecapacityofchangingthecultureofwhole‐of‐government service delivery so that policy makers always take health into consideration”QueenslandHealth(2003,p.56).

Thevalueof stakeholder involvement inHIA isdemonstratedby theGood forKids.Good for Life.Equity‐Focused Health Impact Assessment (Trindall and Bell, 2008). The whole HIA is aimed atensuringadequateconsiderationofAboriginalneedsandculturalrequirements.Thereisnoexplicitdefinition of equity or of what would be considered inequitable. Nonetheless there is evidencethroughout the HIA that Aboriginal representatives were able to shape the HIA process to beresponsivetotheircultureandpopulationneeds,i.e.challengingthedominantculturerepresentedin theHIAprocess. In this sense thisHIAconsidersdifferentials inpower (to shapesocialnorms)within the HIA process, and makes appropriate adjustments. Similarly, the recommendationsincludemanythatareculturallysensitivetoAboriginalcommunities.

Examplesfromthepeer‐reviewedliterature

Jobin (2003) andUtzinger et al (2005) bothdescribe anHIAof a largeoil project inAfricawheretherewere potentially significant inequitable health impacts resulting from the project but thesewerenotable tobeadequatelyaddressedwithin theHIA. Somefactors thatarealso likely toberelevanttothesuccessfuldevelopmentofHEIAonaglobalscaleareidentified:

• publicconsultationsbeingheldinpresenceofarmedsecurityforces;• NGOsbeingfocusedonhumanrights,environment(notspecificallyonpublichealth);• potentialimportantrolethatcivilsocietyorganisationscanplayinmonitoring;• importanceofsupportfromthosewithpower(forexample,theWorldBank);• successshouldnotrelyonthe‘internalmotivation’ofprojectproponents.

Equityinotherrelatedareas

TheHealthEquityAssessmentTool(HEAT),NewZealand

HEAT(Signaletal,2008)isdesignedforusebythehealthsectortohelpthemunderstandtheirrolein improvinghealthequity. It isnota fullHIA, rathera tool thancanbeusedwithanHIAorasa


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standaloneprocess.Thetoolisasetof10questionsthatcanbeusedtoassesstheimpactonhealthinequalitiesofpolicy,programmeorserviceinterventions(Signaletal,2008,p.6):

1. Whatinequalitiesexistinrelationtothehealthissueunderconsideration?2. Whoismostadvantagedandhow?3. Howdid the inequalitiesoccur?Whatare themechanismsbywhich the inequalitieswere

created,maintainedorincreased?4. Where/howwillyouintervenetotacklethisissue?5. HowwillyouimproveMāorihealthoutcomesandreducehealthinequalitiesexperiencedby

Māori?6. Howcouldthisinterventionaffecthealthinequalities?7. Whowillbenefitmost?8. Whatmighttheunintendedconsequencesbe?9. Whatwillyoudotomakesuretheinterventiondoesreduceinequalities?10. Howwillyouknowifinequalitieshavebeenreduced?

The10questionscanbeusedquickly togiveanoverviewof thehealthequity impactofapolicy,programmeorservice,oritcanbeusedtoconsiderequityimpactsinmoredepth.Asubsetofthequestions can be used if that is deemed appropriate. The guidance includes tables and checklistsdesignedtofacilitatetheprocess.HEATcanbeusedalongsideotherstrategicplanningtoolssuchasHIA.

Themodelofhealthemployed isasocio‐economic‐environmentalone;healthequity isdefinedas“Absenceofunnecessary,avoidableandunjustdifferencesinhealth”(Signaletal,2008,p.28).Nodistinction is made between health inequalities and health inequities, both describe healthdifferencesthatare“unnecessary,avoidableandunjust”.Māori,Pacific,low‐incomegroupsshouldbe represented when using the tool. Subgroups identified are ethnicity, gender, socio‐economic,geographical,peoplewithdisabilities.

Equitygauge

The Global Equity Gauge Alliance (GEGA) is an international network of groups in developingcountries that facilitate processes designed to confront andmitigate inequities in health. In 1999and2000,aseriesofmeetingsinvolvingresearchersandactivistNGOsnotedthat,despitethe1978Alma‐Ata Declaration, which emphasizes the importance of equity for the attainment of goodhealth,inequitiesstillprevailedandcontinuedtogrowworldwide.

GEGAhasthree‘pillars’(GEGA,2003).MeasuringandtrackingtheinequalitiesandinterpretingtheirethicalimportarepursuedthroughtheAssessmentandMonitoringpillar.Thisinformationprovidesanevidencebasethatcanbeusedinstrategicwaysforinfluencingpolicy‐makersthroughactionsinthe Advocacy pillar and for supporting grassroots groups and civil society through actions in theCommunityEmpowermentpillar.Actionsareinterconnected.

GEGAissimilartoHIAinthatinadditiontoidentifyingequityissuesitincorporatesconcreteactionstoreduceunfairdisparities.

Inherent within the Equity Gauge concept is an understanding that the determinants of healthinequities are largely socio‐political in nature, and often relate to unfair distributions of power,


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influenceandwealth.Therefore,achievingamore justdistributionofresourcesneededforhealthrequiressomedegreeofsocialandpoliticalmobilization(GEGA,2003).

ExamplesfromEquityGaugescouldprovidevaluableinformation,toolsandguidancethatcouldbeincorporatedintoaHEIAapproach.ForexampleScottetal(2008)describe:

• A list of questions that guide the assessment. These include questions related to generalstate of inequity, government, other decisionmaking and power broking institutions, civilsocietyenvironment,macro‐economicandpublicpolicyenvironment,healthcaresystem.

• Monitoring is similar to profiling in HIA and includes qualitative as well as quantitativeindicators(forexamplecasestudies,narrativeapproachtoreporting.

• Aframeworkforidentifyingsocialgroupstocompare.• Advocacy involves a set of organised actions to support pro‐equity policy and its

implementation.• Developmentofstakeholdermapswhichincludetheidentificationofstakeholdersthatmay

resistorsupportactionsandgoals.• Community empowerment pillar separate from advocacy pillar. This involves actions that

support community empowerment and help communities to speak more effectively forthemselves.

• Bottomupdevelopment.

EnvironmentalJusticeandHumanRights

Withan increase in interest inHIA intheUSwearealsostartingtoseestronger linksbeingmadebetweenenvironmental justice andHIA. Environmental Justice developed from thepublicationofevidence (from studiesbut also local protestmovements) that showed thatpolicies, programmesandprojectsthathaveenvironmentalimpactstendtonegativelyimpactmoreonalreadyvulnerablegroups‐thesegroupsbearanunfairburden(Bass,1998).

It is interesting to note that the link between environmental justice and the concept of equity isoftennotmadeexplicit(BhatiaandWernham,2008,forexample).Howeverinapaperbasedontheexperience of HIA in urban contexts in Australia, Harris et al (2007) do identify the link betweenequityandtheconceptofenvironmental justice.This isseentoprovideanopportunity forHIAtobuild on the environmental justice movement and strengthen its focus on health inequality.Assessingdifferentialhealthimpactsofurbanregenerationprogrammesacrossage,gender,culture,socio‐economicstatusanddisabilityisgivenasanexample.

Right toHealth ImpactAssessment isadeveloping field. Severalhumanrightsmonitoringbodies,includingtheUNCommitteeontheRightsoftheChild,theUNCommitteeonEconomic,SocialandCultural Rights, as well as the UN Special Rapporteur on the right to health, have called ongovernmentstoperformhumanrights‐basedimpactassessments.MembersoftheHIAcommunityhave also endorsed this development. For example, Scott‐Samuel and O’Keefe identified humanrights‐basedHIA“ascentraltothedevelopmentofhealthyforeignpolicyonaglobalscaleandtothedevelopment of globalization as if healthmattered” (Scott‐Samuel & O'Keefe, 2007, p.215). Newmethodologiesarebeingdevelopedandexistingmethodologiesadapted toassess impactson therighttohealth(RTHIA)(forexample:Asher,2004;People’sHealthMovement,2006).Theimmediatepurposes for RTHIAmethodology are (a) identification of impacts that particular state actions, inparticularinrelationtopolicies,arelikelytohaveonpeople’srighttohealth,and(b)identification


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of modifications to policies that may be necessary to minimize negative and enhance positiveimpacts.

There are obvious links between RTHIA and HEIA. From a human rights perspective, integratinghuman rights intopolicy‐makingprocesses, through impact assessment andother evidence‐basedtools for policy analysis, is necessary for governments to abide by their human rights legalobligations. From the perspective of HIA and HEIA, human rights provide a legally binding andmorally compelling framework forevaluating theevidenceandoptions. LinkingHIA to rightsandconceptsofjusticecouldbeoneusefulwayofconceptualisingandalsostrengtheningHEIA.

Complexityandevidence

ComplexityisathemethatisdevelopinginmorerecentHIArelatedliterature(forexample:Simpsonetal,2005;Utzinger,2005;Curtis,2008;Patzetal,2008).Complexityscience,ortheory,respondstotheviewthat

linearrelationsandcorrelations,lineartrajectories,linearreportformatsandlinearnarrativesmakeforverypoorrepresentationofcomplexphenomena.Whetherembeddedinquantitativeanalysesorqualitativedescriptions,suchEuclideanformsareoflimitedinterpretivevalueandhavevirtuallynopredictivevalue,asisprovendailyinstockmarkets,classroomsandpersonallives(DavisandSumara,2005,p.313).

Patz et al (2008) in a paper on comparative risk assessment and climate change identify HIA asprovidinga framework that “encouragesanalysisof synergisticpressuresonenvironmentalpublichealth”(Patzetal,2008,p.28).

Curtis (2008), in a paper identifying some of the potential limitations around using HIA of publicpoliciesinaddressinghealthinequalitieswithinaEuropeancontext,arguesthatthereisashiftfromlineartonon‐lineartheoriesofknowledge.ThechallengesaroundparticipationarehighlightedandCurtis(2008)concludesthat

meaningful participation in HIA consultation, rather than producing an orderly consensus,often appears to involve a multiple field of competing knowledges and contradictorycertaintiesamongdifferentactors,whicharefeaturesofnon‐linearknowledge(Curtis,2008,p.299).

Curtis(2008)callsforawiderrangeoftypesofknowledgetobeused.Forexample,theuseofsocialandgeographicaltheoriesandevidenceshouldbeusedtoinformhealthypublicpolicyalongsidethetraditionaluseofepidemiological andmedical theoriesandevidence. Shebelieves that this couldleadustochallengetraditionalresearchonthegeographyofhealthinequalitiesinvariousways.

Contextandvalues

The importance of local and global contexts has also been identified (Curtis, 2008). This leads todiscussion about how health inequalities can be ‘delineated and localized’. There are challengesidentified inpotentialnon‐transferabilityofsettings. ‘Cultural’andsituationaldifference inhealthprotectioncanalsobeapotentialsourceofinequalities.Curtis(2008)issuggestingthatweneedtolook beyond the immediate area and that “notions of scalemay be the product of social powerrelations”(Curtis,2008,p.296).Curtis(2008)goesontodiscussthephenomenonof‘post‐national


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communities of risk’ with processes that produce effects operating not just at local level. Forexample:

• EuropeanUnionlevel(e.g.SEAprotocol,Art152),

• InternationalstatutoryagenciessuchasWHOandalsolessformalcoalitionssuchasNGOs,consumerprotectiongroups,professionalnetworkssuchasIAIA.

ConnellyandRichardson (2005)arguethatwecannotdebateStrategicEnvironmentalAssessment(SEA)proceduresseparatelyfromquestionsofvalue.TheissueofconflictingvalueshasrelevancetoHEIA.Thereappearstobeadebate inSEAliteraturesimilartothat inHIAaboutparticipationandexpertdrivenassessment.Authorssuggestthatunderlyingvaluesmightbeacauseofsomeofthedisagreement.

Because fundamental questions of value difference are not being explicitly addressed inproceduraldebates,certain interpretations,orwaysof thinking,maycometodominateSEApractice, without the SEA community being able to consciously identify the values which itbelievesshoulddriveassessment(ConnellyandRichardson,2005,p.393).

Connelly and Richardson (2005) argue that decisions about the aims and design of policy areessentiallyquestionsof valuebecause theyarebasedonwho shouldbenefit from thepolicy andwho should not; this “creates a series of conceptual, practical, and political difficulties for anyproposedmechanismfor implementingsustainabledevelopment”(ConnellyandRichardson,2005,p.394).

Summary

Our review indicates that equity is still not being addressed adequately within HIA with theexceptionofEFHIA. In linewith theEFHIA review, thescoping review found that ingeneralevenwhen HIAs were described as having a specific focus on consideration of equity they did notgenerallymovebeyondidentifyingvulnerablepopulationgroupsanddifferentialimpacts.

The reviews of HIA guidelines show that a number of new guidelines have been developed thatincludeamoreexplicitfocusoninequities/ inequalities,oftenwithtoolsandguidanceforhowtoincludeequityorhealth inequalities in thevarious stagesofHIA. Disappointingly, there is stillnoconsistencyinthedefinitionsofequity/ inequityor inequalityused. Ifthesetermsaredefinedatall; often they are inferred through the model of health employed in the guidance. Without aconsistencyinthisterminologyitisdifficulttoseehowanequityfocuscanbeconsistentlyappliedwithinHIA.Theconceptofequityastheabsenceofavoidableandunfairdifferencesinhealthstatusacrosspopulationsubgroups,necessarilyleadstotheneedtomakevaluejudgementswithintheHIAprocess. The importance of values is rarely acknowledged and there are no tools to help judgefairness. EFHIA addresses this through the guidance that such values need to be explicitlynegotiated in the scoping phase of the HIA, and decisions on equity negotiated as part of theassessmentandrecommendationssteps.

Afewoftheguidelinesarguefortheinclusionofconsiderationsofequity/inequalitiesinallstepsoftheHIA;mosttools focusonthescreening,scopingandassessmentphases. There is littlehelp inincluding equity within the results and recommendations. Equity is most frequently addressedthrough the assessment of potential differential impacts on vulnerable or other populationsubgroups.Thesegroupsmaybedefinedaheadoftheimpactassessment,ormaybeidentifiedas


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partofthescopingandscreeningphases.Someguidelinesargueforaminimumsetofsubgroups,usuallyrace,gender, income,andsoforth,withothersidentifiedaspartoftheprocess. Thisbegsthequestionastowhetherattemptingto‘levelup’thepotentialimpactsofpoliciesisthesameasimprovingequity.Isthefocusonvulnerabilitysufficient?

ThereviewsofHIAsmirrorthefindingsoftheguidelines,perhapsnotsurprisinglyso.Again,thereisinconsistency in thedefinitionanduseof theequity / inequalities terminology.MostHIAsdiscusshealthinequalitiesor,perhaps,equity,butdonotthenemployastructuredapproachtoassessingimpactsonequityorinequalities.Wherethisisdone,itisdonethroughsubgroupanalysesandtheinclusionofrepresentativesofcommunitygroupsintheSteeringGrouporthroughconsultationinthe assessment phase. It does not necessarily follow that such participationwill lead to greaterequity.Often,evenwheretheassessmenthasincludedconsiderationofdifferentialimpacts,theseanalysesarenoteasytotracethroughtotheresultsandrecommendationsofHIA.TheQueenslandHealthHIAofserviceintegrationhighlightedthelackofassessmentofthe‘causesofthecauses’ofhealthinequalities/inequitiesasalimitationoftheHIA.Suchassessmentsofdistaldeterminantsofhealthareveryrare.

TheinclusionofequitywithinHIAiscomplex,difficultandtimeconsuming.

ProcessevaluationsofHIAsdemonstratethattheycanhavevaluebeyondtheir recommendationsand potential impact on policy development and implementation. The process itself provides anopportunityfor inclusion–differentsectorsanddifferentsocialgroups–andforafor learningthelanguage of equity and of other organisations, fostering a shared understanding and greatercollaboration.SomeofthesebenefitsmayextendbeyondthelifeoftheHIAandhavebeenshownto lead to greater inter‐sectoral working and improved inclusion of Māori in local governmentdecisionmakingprocesses.

LinkingHIA to theenvironmental justiceandright tohealthmovementsprovidesopportunities tostrengthen the equity component of HIA. Environmental justice has an explicit focus onvulnerability, and linking to the human rights agenda could provide a legally binding andmorallycompelling framework for evaluating evidence and options within HIA. Complexity theoryemphasises the need to incorporate a broad spectrum of evidence within HIA, to ensure thatmultiple perspectives and ‘knowledges’ are included. This would, of course, require that thedifferentvaluesystemsofdifferentparticipantsbemadeexplicit,asshouldthevaluesunderpinningtheHIA.Andweshouldexpectconflictanddifficultyinnegotiatingresultsandrecommendations.

HEIA scoping project Interviews

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4:Interviews

Introduction

Theinterviewswereconductedwith14peoplewithexpertiseinhealthequityand/orhealthimpactassessment. Theparticipantshadbeen identifiedthroughaprocessofstakeholdermapping. Theinterviews tookplaceduringAugust and September2009andweremainly one‐to‐one interviewsconductedoverthetelephone.

The interviews aimed to explore the participants views on the effective incorporation of equitywithin theHIAprocess. Wediscussed thenatureofhealthequity itself, the influencesonhealthequity at the global, regional, national and local levels, the strengths and limitations of HIA inconsideringhealthequity,andfinallywhetherornotthereistheneedforanewHEIAmethodology.

Methods

Interviewparticipants:

TheinterviewparticipantshadexpertiseinoneormoreoftheareasofHealthImpactAssessment,health equity, policy impact on health equity at the global, national and / or local levels, healthequity measurement and the WHO Commission on Social Determinants of Health. They wererepresentativeofthefollowinggroups:

• Gender:7women,7men;• Occupation:5practitioners,5academics,4academicpractitioners;• Region:5fromtheUK,1fromEurope,2fromCanada/US,3fromAustralia/NewZealand,

andoneeachfromChile,SouthAfrica,Thailand;• Expertise:7withpracticalknowledgeofhealth(equity)impactassessmentmethodologiesor

healthequitytools,and7withotherhealthequityknowledgeandexperience.

Interviews:

14outof the16people invitedtotakepart in theprojectagreedtobe interviewed. Twopeoplewereinterviewedtogether,sotherewere13interviewsintotal.Theinterviewstookplacebetween18thAugust2009and8thSeptember2009.Eachparticipantwassentwritteninformationabouttheprojectandaconsentform,whichtheywereaskedtoreturnviafaxoremailbeforetheirinterviewtookplace.Thejointinterviewwasconductedface‐to‐face,therestwereoverthetelephone.Themeaninterviewtimewas60minutes.Allinterviewsweredigitallyrecordedandthentranscribed.AthematicanalysisoftheinterviewtranscriptswasundertakenusingNVivo8.

Interviewquestions(thefullinterviewscheduleisgiveninAppendixC):

The interview schedulewas designed to explore the participants’ knowledge and opinions in thefollowingareas:

• Healthequity:definition,factorsthatalterhealthequity,actionstoincreasehealthequity• Thebarriersandfacilitatorsforpolicychangetomaximisehealthequity• Thedifferentfactorsforandimpactsonhealthequityintheglobal,regional,nationaland

localgeographicalregions,andthemethodologiesrequiredtoassessthesefactorsandimpacts.

• Forthoseparticipantswithexperienceinhealthimpactassessmentwewereinterestedin:


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o Thestrengthsandweaknessesofcurrentimpactassessmentmethodologiesandtools;

o Thebarriersandfacilitatorsforassessinghealthequityimpactswithinthosemethodologiesandtools;

o Thebarriersandfacilitatorsforimplementingrecommendationsaimedatincreasinghealthequity;

o Howtoincreasetheuptakeofrecommendationsaimedatincreasinghealthequity;o Whetherornottheythoughtahealthequityimpactassessmentwoulddifferfrom

HIAasitisnowused.

Keyfindings

Theanalysisispresentedinthesamecategoriesassetoutintheinterviewquestionssectionabove.

HealthEquity

a) Definition: It is perhaps not surprising that the participants had similar definitions for healthequity. There was a clear moral aspect to the definitions, although this was expresseddifferently;fourkeyaspectsofhealthequityemergedfromtheinterviewdata:

i. Health equity is the distribution of health in a just society, so that individuals shouldhave the opportunity to live a decent life and achieve their full health potentialregardlessoftheirgender,religion,income,wheretheylive,whatjobtheydo,etc.Theyshouldhaveaccesstohealthylivingandworkingenvironments,affordableandreliablehealthservicesandeducation.

ii. Social justice can be characterised as the fair distribution of: power; ownership andcontrolofbasicresources;resourcesforhealthandhealthyliving;goodsandservices.

iii. Health inequity is the avoidable and unfair differential distribution of the impacts ofpolicies, programmes and life chances on different sections of society (based on age,gender, socio‐economic status, disability, ethnicity / culture, and so on). Thesedifferences are avoidable because they aremodifiable through public policy or otherinterventions. The underlying influences on these distributional differences relate topowerdivisionsandsocialhierarchywithinsociety.

iv. Healthequityneeds tobea focuswithinpolicydevelopmentandorganisationalgoals,and also needs to be visible in planning and impact assessment. Public organisationsneedtobeaccountabletothepopulationstheyserveandthosepopulationsneedtobeempoweredtodemandhighqualityservices.

Inaddition,thereweresomecaveatsaboutdefininghealthequity.Itshouldbenotedthatthedefinitionofhealthequityandhow it isput intooperationwillbeculturally specificandmay,therefore, vary by country. Even within the same organisation different definitions of healthequitymaybebeingused,andthismaycreateconfusioninpolicydecisions.Asspecificlanguagebecomesmoreembedded,definitionscaneventuallybecomeshort‐handforthephenomenontheyrepresent,andit ispossiblethateventuallywelosesightofwhatwasoriginallymeantbythatterm.

b) Factors: The participants identified the following as the main factors contributing to healthequity:


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i. Structural factors suchaspoverty, includingpovertyof expectation. Those conditionscollectivelyacknowledgedassocialdeterminantsofhealth,suchaseducation,income,ahealthy livingenvironment,andso forth.Thewaysuchsocialdeterminants interact toinfluencetheopportunitiesthatpeoplehavetoliveareasonablelife,andthewaytheseinfluencesinteractacrossthelife‐course.Inequalitieshavetheirrootsinhistoricalsocialandpoliticaldevelopments.

ii. Politicsandpolicy.Theinfluenceofpublicpoliciesonthematerialandsocialconditionswithinwhichpeople live, and the lackof evaluationof the impact of policyonhealthequity.Thelevelofpoliticalcommitmenttoimprovinghealthequity,reflectedinlevelsofsocialdemocracyandtheprovisionofsocialsafetynets.Thelackofdemocracyatalllevelsofdecisionmaking.

iii. Access to affordable and reliable health services. This is generally accepted as acontributory factor to health inequity in the Global South and less of a factor in theGlobal North. There was an example from Australia, however, that showed howincreased co‐paymentswithin thehealth serviceshad led to reducedaccess tohealthserviceswithinthatcountry.

iv. Power and control. Not feeling in control of one’s own life and opportunities. Thedistributionofpowerwithinandbetweensocietiesandbetweencountriesandglobalormultinational organisationswas seen as a key factor underpinning the distribution ofhealth outcomes. Associated, but slightly different factors are: the control overauthority–whomakesthedecisions,andhow;thecontroloverinformation–howandwhatinformationispresented,howissuesaredescribedandexplainedandtheroleofthemediainthis;controloverregulation–especiallyatthegloballevel.

v. Injustices: one participant felt strongly that underlying these factors are fundamentalinjusticesinsocietyarounddiscriminationagainstpeoplebecauseoftheirrace,gender,incomelevel,andsoon.

vi. Differencesinlanguageandculture.

c) Actions to improve health equity would address the factors affecting health equity set outabove,buttheparticipantsalsoidentifiedotheractionsthatcouldbetaken.

i. Policyandpolitics:Promotesocialdemocracyandtheintroductionofsocialsafetynets;promote decision making for health equity; strengthen global regulatory structures;addresstheunderlyinginfluencesonandstrengthenthepositivesocialdeterminantsofhealth;recogniselife‐courseinfluences;moveawayfrombehaviourchangemodelsandinvest in these long‐term approaches; promote inter‐sectoral action; strengthen theinfluenceof thehealth sector; improve access to health care. Such changeswill taketime; in the short‐term target action where there is evidence that it will make adifference.

ii. Communities and civil society: A number of participants felt that communitydevelopment and community empowermentwere key to improving health equity. Itwould help people to feel more in control of their circumstances and through thisprocess people could be educated about their civil rights. HIA could be used as anadvocacy tool to raise awareness amongst policy makers of social determinants ofhealthandhealthequityandtheimpactthatapolicymayhave.


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iii. Pressureforchange:Empoweringcommunitiesinthiswaywillhelptocreategrassrootspressure for better health equity; engagewith themedia to raise awarenessof socialdeterminants of health and health equity, and to promote the message that healthinequitiesarenotjustanissueforpoorercommunitiesbutthattheyaffectthewholeofsociety.Atthegloballevel,civilsocietycanalsocreatepressureforglobalhealthequity.As Global South (e.g. Brazil, India, China) economies become stronger and gainmorepowerintheglobaleconomyitcreatesanopportunityforthemtopressforchangeinglobal financial regulatory structures and to introduce a different set of values moresympathetictotheissueofequity.

iv. Championsareimportantingeneratingchange.

Some of the participants expressed their concern that focusing on actions to improve healthequitymightmask what can be done to reduce health inequities. The evidence base is notnecessarily there to support action to address health equity, but there is strong evidence toshowwhatcanbedonetoreducehealthinequities.Itispossiblethatworkingtoimprovehealthequitymaybeseenastoobigatask,andsonothingwillbedone.

Globaltolocalfactors,issuesandmethodologicalrequirements

Therearefourareasofinterest:Firstly,issuesrelevanttobothlevels;secondly,issuesspecifictothenational / local context; thirdly, issues specific to the global / regional context; fourthly, theinteractionbetweenthesetwolevels.

a) Issuesrelevanttobothlevels:

i. Researchisneeded:tounderstandtheprocessesofchangeateachlevel;tounderstandthestructuresofdecisionmakingateachlevel;tounderstandtherelationshipbetweendemocracyandhealth;

ii. Ateachlevelpoliciesshouldbeinformedbytheprioritiesthenextleveldown,facilitatedbyabottom‐uppressureforhealthequity;

iii. Recognise the context within which the impact assessment is being conducted: timeconstraints; transparency of the policy being assessed; place and culture; politicalcontext–howsupportiveisthepoliticalenvironment?

iv. Methodsand tools: Specific toolswouldneed tobedeveloped for specific issues. In‐depth policy analysis would be able to explore the complexity of the global policyprocessandtheinfluenceofglobalpoliciesinlocalsettings. Thispolicyanalysiswouldinclude an historical analysis of the development of that policy as well as theinteractionswithotherpolicy. Itwouldtaketimeandsowouldnotbesuitable forallpolicies. Itwouldhelptoexposethedistributionofpowerinthepolicyprocess. Suchanalyseswouldbemuchmorecomplexattheglobal level,withmanymore influencesonthepolicydevelopmentand implementation. Theremaynotbethecapacitytodosuchdetailedanalysesatthelocallevel.

b) Issuesspecifictothenational/localcontext:

i. Therearedifferentsocialcontextswithinacountry.Someareaswillhavesmallpocketsofdeprivationandotherswillhavesmallpocketsofaffluence. Theactionstoincrease


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health equity orminimise health inequities compared to the national averagewill bedifferentineachoftheseareas.

ii. The political context and level of public awareness of the issues will affect action toaddresshealthequityinthenationalorlocalcontext.Aswilltheleveloforganisationalcapacitytodoso.

iii. Makinghealth equity assessment a legal requirement could focus attentiononhealthequity, although this then runs into the danger of becoming burdensome and soreducedtoatick‐boxexercise.

c) Issuesspecifictotheglobal/regionalcontext:

i. ThedominanceofglobalfinancialinstitutionssuchastheWorldBank,theInternationalMonetaryFundandtheWorldTradeOrganizationarefactorsattheglobalandregionallevels.Forexample,StructuralAdjustmenthashadanegativeimpactonhealthequitywithin and between countries. There are concerns about the accountability of theseinstitutions and powerful individuals, such as Bill Gates. This lack of accountabilityallows their values and priorities to dominate global processes, even when theirintentionsaregood.Tradeagreementsandwaterrightswerebothfactorshighlightedatregionallevels.

ii. Methodologically, the context for policy development and implementation becomesmorecomplexasonemovesfromthelocaltotheglobalarena.Thecomplexityofpolicydevelopmentattheinternationallevelmeansthatdifferenttoolsandindicatorsmaybeneeded forassessing thehealthequity impactsofpolicies. Oneparticipant suggestedthatcountrieswithagreaterknowledgeoftheglobalandregionalinfluencesonhealth(such as trade agreements) could develop tools for assessing their local impacts thatcouldbesharedglobally.

d) Theinteractionbetweenthesetwolevels:

i. The local impact of global policies and processes: Actors at the global level are notgenerally concerned about the local consequences of their actions. Aside from theactivitiesoftheglobalfinancial institutionsoutlinedabove,otherglobalprocessesthathaveanimpactlocallyincludetheglobalspreadoftechnologyandtheglobaldiffusionofculture.Forexample,differentemploymentandsafetyregulationsindifferentcountriesaidthemovementofproductionaroundtheglobesothatharmfulprocessesorproductscancontinuetobeusedinthemanufactureofgoodstobesoldglobally.Longtermfoodsecurity is an increasing concern. Global pressures on land in the Global Southunderminethesecountries’abilitytoensuretheirownlong‐termfoodsecurity:growingflowers instead of food in Kenya; rich countries buying land for food production inpoorercountries.Theglobalspreadofculturecanhavenegativeeffectslocallyintermsofundermininglocalidentitiesandinfluencingpersonalchoices;suchaschangesindietto less healthy foodstuffs (such as sugar rich cereals replacing traditional breakfasts,drinking sugar densedrinks like CocaCola insteadof fruit juice, and eating fast foodssuch asMacDonalds). Thesemultinational corporationsmay adapt their products tolocalpalatesand foodregulations inorder tosecureaplace in thosemarkets. Globalpricing policies may also affect what foods are available and affordable locally – for


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example,despiteproducingasurplusinmilknationallythepriceofmilkinNewZealandmeansthattherearesomewhocannotaffordit.Theselocalimpactsaredifferentiatedbyclass.

ii. Assessingthelocalimpactofglobalprocesses:localpractitionersdonotnecessarilyhavesufficientknowledgeofglobalprocesses;lackofaccesstoprocessesatthegloballevelforcesafocusatthe local level; localpractitionersneedhelpwithtoolstoassess localimpactsofinternationalpoliciesandagreements–thesecouldbedevelopedgloballyforlocaluse; there is also theneed toassess theglobal footprintofnationalpolicies, forexampleinternationalrecruitmentofhealthservicepersonnel.

iii. HIA is still a relatively new methodology. The Global North dominates in thedevelopment and undertaking of HIA. However, there is still a lack of capacity forconducting HIA in the Global North and more so in the Global South. There wereconcerns expressed about the potential impacts of HIAs done in the Global South bypractitionersfromtheGlobalNorth.Thesepractitionersmaylackunderstandingoflocalculturesandcontexts. Where thesepractitionersworkoutside thehealthequity fieldtheymaynotbefamiliarwiththeconceptsofequityorsocialdeterminantsofhealth.

Barrierstoandfacilitatorsforpolicychangetoimprovehealthequity

Barriers

Keybarrierstopolicychangetoimprovehealthequitycentrearoundperceptionsofhealth,healthequityandinequity,thepoliticalcontextandthedistributionofpower.

Therearemanydefinitionsofhealthandthebiomedicalmodelisdominantamongstthem.Thishasimplications forhow interventionsareplannedand implemented (suchasverticalprogrammes toaddress specificdiseases),butalso forourability toengagepeoplearoundsocialdeterminantsofhealth. For many “health” still means “health care”; this makes it difficult to discuss socialdeterminants. Theconceptof“well‐being” isnot linkedtohealthcareandthebroader influenceson well‐being are more readily accepted and understood. It might, therefore, be better whenengagingwithpeopleonthebroaderinfluencesonhealthtofocusonwell‐beingandtotalkaboutthoseinfluencesthatfallwithintheirremit.

Justashealthfromasocio‐environmentalperspectivecanbedifficulttounderstand,healthequityisalso a difficult concept to grasp. There is a general lack of awareness that health is distributedunevenlythroughoutsocietyandthecontributionthatsocialdeterminantsmaketothis. Thewaythathealthisrepresentedinthemediaaffectspublicopinion;theover‐representationoftheimpactof unhealthy behaviours and medical interventions occludes the discussion, and thereforeunderstanding,ofsocialandpoliticalinfluencesonthedistributionofhealth.Thislackofawarenessreinforces the dominance of the biomedical model and effectively reduces support for broader,upstreamchangesthatwould improvehealthequity. Theseupstreamchangestopromotehealthequity may also be seen as too big to tackle, which in turn can lead to inertia and the focusremainingonmedicalinterventionsandbehaviourchangemodels. Someparticipantswarnedthatfocusingonpromotinghealthequitymaydistractattentionfromtheexistingevidenceofwhatcanbedonetotacklehealthinequities.


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Withinorganisationstheremaybealackofcapacitytoworktowardspromotinghealthequity.Forsomeorganisations, suchas thehealthcareservices, theremaybeaneedto redistributeexistingresourcesawayfromthebetter‐offareas,whichtendtobebetterserved,tothelesswell‐offareas,whichtendtobeunderserved.Thisimbalanceinthedistributionofresourcesmaygounrecognised,ormaynotbeaddressed. In addition, theremaybea lackof sufficientdataat the local level todescribetheextentofhealthinequities,andalackofpeoplewiththenecessaryskillstounderstandhealth equity and to work across boundaries to address health inequities. For public sectororganisationsprioritiesfromcentralgovernment,intermsofperformancemanagementandfundingallocations, may favour addressing disease‐based (such as cancer and diabetes) and behavioural(suchassmokingandobesity)outcomes,ratherthanaddressingupstreamcausesofhealthinequitythroughcollaborativeworking.

The extent to which organisations embrace the challenge of promoting health equity and / orreducinghealthinequitieswill,insomepart,bedeterminedbytheprevailingpoliticalculture;thatistosay,theextenttowhichthedominantpoliticsvaluespromotinghealthequityandispreparedtomakethenecessarystructuralchangestodoso.Ithasalreadybeenmentionedthatpressuresandprioritiesfromcentralgovernmentcanconflictwiththeabilityoforganisationstoworktogethertoimprove health equity locally. In addition, the dominant political culturemay act as a barrier topromotinghealth equity through: prioritising economic concerns over social andhealth concerns;beingunwillingtogiveuppower–healthequityrequiresamoreevendistributionofpower;alackofsupportforthevaluesunderpinninghealthequity,oftenassociatedwithright‐winggovernments;lackofevidence‐basedpolicymaking–policiesaremadetofitpoliticalprioritiesratherthanbasedontheevidenceofwhatisneeded.OneparticipantgaveexamplesofwhereNGOsworkinginarichcountryhadtheirfundingwithdrawnbecauseoftheiradvocacyforsocialjustice.

Severaloftheparticipantsidentifiedtheimbalancesinthedistributionofpowermentionedearlieras keybarriers to action to improvehealth equity. Thesepowerdifferentials aremanifest in thedominanceofglobalorganisationswiththepowertopromoteandprotecttheprimacyoftradeandeconomic priorities over social and health concerns; in the globalisation of culture and valuesassociatedwith these processes; nationally and internationally the dominance of the ideology ofindividualism andmarket fundamentalismmakes it difficult to connect these processes to healthoutcomes. This power over knowledge and ideas extends to theways inwhich evidence can bedistortedtoleadtofalseunderstandingsofissuesinordertopromotepoliticalprioritiesorvestedinterests.Politicalcorruptionisanextremeimbalanceinpowerthatworksagainstthepromotionofhealthequity. Buteven inmorebenign formspower imbalances can leadgovernments to fail torecognise that people at the grassroots are actors in the implementation of policies andprogrammes, and that these grassroots activistsmaynotuse thepolicies andprogrammes in thewaythatwasintendedoranticipated.

All of the above canbe considered countervailing forces – evenwherepolicies are introduced toimprove health equity or reduce health inequities, these barriers will limit the success of thosepolicies.

Facilitators

Participants suggested several facilitators for policy change to promote health equity. These areessentiallydifferentmechanismsforraisingawarenessofhealthequityissues.


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The first is todowithmaking theargumentsandvaluesassociatedwithhealthequity visibleandpalatable.Suchbottom‐uppressuremaytaketheformofgrassrootscollectiveactionandpressurefromlocalgovernments.ToolssuchasHealthImpactAssessmentsalsoservetoraiseawarenessofsocialdeterminantsofhealthwithinbroadpartnershipsofindividualsandorganisations.

Secondly,opportunitiestoputtheseissuesonpoliticalagendascomewithchangingpoliticalcycles,changesthatcausere‐evaluationofthestatusquo–suchasthecurrenteconomiccrisis,legislationinrelatedareas–suchaspublichealth,humanrightsandsocialinclusion,andshiftsinthefocusofresearch–forexamplethere‐emergenceofsocialepidemiologyintheUnitedStates,whichaffordstheopportunitytoexaminelinksbetweensocialpolicyandhealth.

Lastly,these“policywindows”(Kingdon,1995)arebestcapitaliseduponwhentherearechampionsin place to bring issues and opportunities together. These champions may be sympatheticpoliticians,activists,keyworkersorinternationalagencies.

EquityinIAmethodologiesandtools

Theparticipantswereaskedtoconsiderhowequityisincludedwithinimpactassessmenttoolsandmethodologies. The participants felt that equity is oftenmissed in theHIA process. Consideringequity intermsofdifferentialhealth impactsaddsa layerofcomplexitytoHIAthatbecomestimeconsuming. HIA is often requiredwithin short time framesand so suchexplicit considerationsofequitycanbelost.

ItwasfeltthatequityshouldbeembeddedthroughouttheHIAmethodology,however.Toolssuchas the Dahlgren and Whitehead “Rainbow Model”1 of social determinants of health and thePROGRESS‐Plus2couldbeusedasanequitylenstoaiddiscussions.Thespecificpopulationgroupsthatwouldbeaffectedbythepolicyshouldbeidentified.Toooftensocio‐economicgroupsareleftoutofsuchanalyses.GenderauditcouldalsobepartofHIA.

Someparticipantsrecommendedin‐depthhealthequityanalysesofspecificissues.TheseanalysesmayfollowtheusualHIAmethodologyormayencompassresearchstrategiesexaminingthehealthequityimpactsofapolicyfromdifferentperspectivesandovertime.Eitherwaytheyarelikelytobeingreaterdepth,offermoreinsightintothehealthequityimpactsbutmaytaketoolongtobeusefulinthepolicydevelopmentprocess.

TherearestrengthsandweaknessestotheHIAmethodologiesgenerally.Likeothersuchtools,HIAcanbeignoredorthefindingsmisused,especially if itbecomestoo‘tick‐box’. Ontheotherhand,HIA can raise awareness of social determinants of health and health equity and can be used foradvocacy. Somefeltthatthereisaneedforastandardisedmethodology;othersthattheexistingmethodologies are sufficient but that there is a need for more tools. Some requested moreguidanceonwhattoolstousewhen.

Barrierstoandfacilitatorsforassessinghealthequityimpacts

Barriers

1Aconceptualmodelofthemaindeterminantsofhealthportrayedaslayersofinfluence(Whitehead,1995,p.23).2PROGRESS‐Plus(Placeofresidence,Ethnicity,Occupation,Gender,Religion,Education,Socio‐economicstatusandSocialCapital+age,disability,sexualorientation,andotherspecificvulnerableorexcludedgroups):Kavanaghetal(2008).


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Anumberofbarrierstoassessinghealthequityimpactswereidentified.Oneclearbarrieristhelackofavailablelocaldata.Thereisbetterdataatthecity,stateandregionallevels,butatthelocallevelthishasnotnecessarilybeencollected in sufficientdepth tobeuseful inassessingequity impactswithin HIA. One participant commented that the data might be suitable for those conductingacademic research,but it isnotmeaningfuloraccessible to thoseworkingatapractical level, forexamplewithin local government. Another participant observed that gathering this local data intheirlocalityrequirescontactingmultiplelocalagencies,notallofwhicharepreparedtosharetheirinformation.Itwasobservedthatwherelocaldataisavailablethewayitisexaminedwilldeterminewhichequityissuesemerge.Thequalityoftheavailabledatawasalsoaconcern.

ThereisalackofcapacitytoconductHIA.ThisistrueintermsofthelackofpeopleabletodoHIA,lackofpeopleabledoHIA to sufficientdepthandquality, andbecause in somecountriespeoplewith the skills to doHIA have toomuch otherwork to do. It is of particular concern that thosecontractedtodoHIAmaynotunderstandtheprocessofresearch,andsowillnotconductHIAwithsufficientrigour.Inadditiontheymaynothavebackgroundsinpublichealthnorunderstandequity,andsosocialdeterminantsofhealthandequity impactsmaybemissed in theHIAs theyconduct.SpecialconcernswereraisedaboutconductingHIAintheGlobalSouthwherecontractorsbroughtinfromtheGlobalNorthtoconductHIAmightnotunderstandspecificlocalcontextualfactors,suchasculturalinfluences,thatimpactontheimplementationofpoliciesandprogrammes.

Thepoliticalcontextcanconstraintheassessmentofhealthequityimpacts;ifhealthequityisseenas a lesser priority than reducing chronic diseases or managing health care costs, for instance.There was some concern that health equity assessments instigated by the organisations whosepoliciesarebeingassessed,orothervestedinterests,mayreceivetheassessmenttheywantratherthananaccurateone.Insomecircumstancestheymaybedonetoreducepoliticalopposition3.

Again,concernswereraisedthat ifHIAorhealthequity impactassessmentisrecommendedtobedoneoneverythingitwillbecomeburdensome,andwillbecometick‐box.ItwasfeltthatifHIAisdonetoolightlyitcouldbeignoredorwouldreinforceexistinginequalities.

Facilitators

Thefollowingweresuggestedaswaysoffacilitatingtheassessmentofhealthequity:

• AminimumsetofstandardsforHIAtoensurethequalityofthefinalassessment;• Having an explicit values base, underpinned by human rights and specifically the right to

health;• Ensuringthathealthequityresearchisofhighquality–thatitisrobustandrigorous;• Internationalacademiccollaboration–totrainpeopleinHIA,tohelpraiseawarenessofthe

issues;• Evaluationsofpolicyimpactsonhealthequity:

o NotjustprospectiveHIAorHEIA;o Concurrent and retrospective evaluations – there is little control over how a policy is

implementedinpractice;

3SeeSmithetal(2010)foradescriptionofhowBritishAmericanTobaccosoughttoinfluencethedesignoftheEuropeanUnionintegratedImpactAssessmenttotheirbenefit.


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o Suchevaluationswouldneed to lookat the impacton thewhole system,not just thepolicyareabeingassessed.

BarrierstoimplementingHIArecommendations

The barriers to implementing equity recommendations from HIA reflect the barriers alreadydescribed. There needs to be political will to act on the recommendations becauserecommendationsforsocialchangemaybethreateningtothoseinpower.Thiscouldbedamagedbynot emphasising thehealth equity benefits of a policy, and focusingon thepotential negativeconsequencesofthepolicy.

Thepolicymakingcontextisalsoimportant.Thepersonorgroupresponsibleforimplementingtherecommendationsmaynothavetimetodoso.Theremaynotbeacultureofevidence‐basedpolicymaking. If the HIA practitioners are consultants, they may not have understood the cultural ornationaldifferencesinthecommissioningcountry:theextentofthedevelopmentofpublichealth;the level of understanding of social determinants of health; local priorities – e.g. environmentalimpactsonhealth,ruralcommunities’accesstohealthcare.

FacilitatorsfortheuptakeofHIArecommendations

Severalclearfacilitatorstotheuptakeofhealthequityrecommendationswereidentified:

• InvolvekeystakeholdersthroughouttheHIAprocess.ItisimportanttoengagewithkeystakeholdersearlyintheHIAprocessandthroughout.Thesestakeholdersshouldincludedecisionmakersfromallsectorsinvolvedandcommunitymembers.A valuable tool is to hold a stakeholderworkshop at the beginning of theHIA to explore theissues.Stepsshouldbetakentomaintainrelationshipswithkeystakeholders,especiallyduringany organisational changes that may occur. This approach creates an opportunity to raiseawarenessandtrainpolicymakersabouthealthequity.

• OfferdifferentpolicyoptionsUseHIAtoofferandassessmorethanonepolicyoption,togivestakeholdersandpolicymakersachoice.ThisisdoneroutinelyinThailand.Framethepolicyoptionstofitgovernmentpolicystatements. Usegovernmentthink‐tanksandusethelanguageoftheagenciescommissioningtheHIAs.InthiswayHIAcangivepoliticianstoolstobackupthemoralargumentforworkingtoimprovehealthequity.

• RecommendationsUsetherecommendationstooffercriticismtoparticipatingagencies;thiscanbewellreceived.Tierecommendationstotheunderlyinginfluencesonhealthequity. Havingrecommendationsforequitycaninfluencetheorderinwhichpolicytaskswilltakeplace.Recommendationsshouldbe aimed at different levels – for individual and organisational change. Set targets for therecommendations,wherepossible.ThiswillaidintheevaluationoftheHIA.

• PressureSimilartofacilitatorsforpolicychangetoaddresshealthequity,pressurefrombelowcanhelpcreate opportunities for the implementation of HIA recommendations. Pressure for greaterequitycancomefromcivilsocietymovements,anditwouldbevaluabletolinkdifferentsocialmovementsworkingtowardsgreatersocial justice. Inordertofacilitatethis,healthshouldbeseen as just one of the issues of concern, and not the priority. There is a need to raiseawarenessthatimprovinghealthequityhasbenefitsforallofsociety.Championsandthemedia


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canbeusedasadvocatesforhealthequitybyraisingawarenessofthelevelofinequalityandtopushfortheimplementationofrecommendations.HIAcanalsobeusedasanadvocacytoolforhealthequity,ifthereportsareinthepublicdomain.

IsHEIAdifferentfromHIA?

Finally, participantswere askedwhether they felt therewas a need for something new to assesshealthequityimpacts;whetherornotHEIAwoulddifferfromHIA.

Twoparticipantsfeltthattherewasaneedforsomethingdifferent,eitheranHEIAmethodologyoranotherwayofevaluatingthehealthequityimpactsofpolicy.Theyfeltthattherewasaneedforamethodologywith an explicit equity focus in order to draw attention to the equity aspect of theassessment.ItwasfeltthatequityhasanexplicitvaluesbasethatisnotnecessarilyincludedwithinHIAasitcurrentlystands.

OneparticipantarguedforanEquityImpactAssessment,wherehealthisjustonefacetoftheequityassessment. Anexampleof this sortofmethodologycanbe found in theRight toHealth impactassessment(seeHuntandMacNaughton,2006).

Most participants felt that the current HIA methodologies are sufficient, however. There wereconcernsabouthavingtoomanydifferentimpactassessments. Thesecouldbecomeburdensome,and there is the danger that a separate HEIA wouldmean that equity is perceived as an optionratherthanintegraltotheprocess.TheseparticipantsfeltthatHIAhasenoughcapacitytoconsiderequityasitstands.Acommonopinion,however,wasthatequityisnotcurrentlyusedwidelywithinHIAandthatthereisaneedtobuildcapacityforHIAandequitywithinHIAinboththeGlobalNorthandGlobalSouth.

Althoughthecurrentmethodologyisconsideredsufficient,itwasfeltthattherewasscopefornewtools:

• In‐depthpolicyanalysisthatwouldsetapolicyinitspoliticalandsocialcontext,identifythekey actors in its development, particularly vested interests, conduct cross‐countrycomparisons, and include an historical analysis of the policy development. Such analyseswould be time consuming andwould therefore not be suitable for all policy assessmentsbut,ifthepoliciesassessedarechosencarefully,wouldprovidein‐depthknowledgeofthepolicydevelopmentprocessanditsimpactonhealthequity;

• Sociological assessments to understand the processes of change at different levels of thepolicyimplementationprocessandpeopleasactorsinpolicydelivery;

• Developnewindicatorsfordemocracyandpowerdistribution;• Includeaframeworkforthinkingaboutequityinpolicydevelopment–e.g.PROGRESS‐Plus

ortheRainbowModel.

A number of participants argued against institutionalising HIA; this could slow down the policydevelopment/ implementationprocessandmight leadtoHIA/HEIAbecomingatick‐boxexercisethatlosesvisibilityandvalue.

TherewasalsoacallforHIAtobevaluesbasedratherthanatechnocraticexercise;andarequestforHEIAtobepilotedintheGlobalSouth.


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Summary

In summary, the majority of the interview participants felt there was no need for a new HEIAmethodology.RatherthereisaneedtostrengthentheequityfocusofHIAthroughcapacitybuildingandnewassessmenttools.

Severalareasofresearchandmethodologicaldevelopmentwereidentified:in‐depthpolicyanalysesincludinghistoricalanalysesofpolicydevelopment;concurrentorretrospectiveevaluationsofpolicyimpactsonhealthequity,takingawholesystemapproach;sociologicalresearchtounderstandtheprocesses of change; explorations of the distribution of power and its impact on health; cross‐countrycomparisonstoassesstheimpactofdemocracyonhealth.

TheparticipantsarguedthatweuseHIAtoexposeandchallengedifferentialsinpowerandthelackofdemocracyandaccountabilityindecisionmaking,especiallyatthegloballevel;anduseHIAasanadvocacytoolatthelocallevel.

Finally,weneed to raiseawarenessofhealthequitybyengagingwith theglobal civil society, themediaandpolicymakers–itaffectsusall.

HEIA scoping project Workshops

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5:Workshops

Introduction

Thefindingspresentedinthissectionarebasedonthediscussionsfromtwoworkshops.Thefirst,andmainworkshop, took place on 5 and 6 October, 2009, in Liverpool. Thiswas theworkshopplannedaspartoftheempiricalworkoftheproject.ThesecondwasmoreopportunisticinthatDrAlexScott‐SamuelhadaworkshopapplicationacceptedfortheHIA09conferenceinRotterdam.Weused this workshop to present the project and explore some of the questions with participantsinterested in HIA, but with differing levels of experience in HIA, and from a broader range ofcountries.

Methods

LiverpoolWorkshop

Participants:

The Liverpool workshop participants were identified through the stakeholder mapping processoutlinedinSection2.TheparticipantshadexpertiseinoneormoreoftheareasofHealthImpactAssessment,healthequity,policyimpactonhealthequityattheglobal,nationaland/orlocallevels,health equitymeasurement, health economics, health rights and theWHOCommission on SocialDeterminantsofHealth.ThemajorityhadpracticalexperienceofHIA,andsomehaddevelopedHIAmethodologies with an explicit consideration of equity or health inequalities. They wererepresentativeofthefollowinggroups:

• Gender:12women,7men;• Occupation:1wasanHIAconsultant,2workedfortheEnglishDepartmentofHealth,1

workedfortheEuropeanUnion,3workedwithintheUKNationalHealthService,1workedforanationalPublicHealthorganisation,2workedwithinlocalorregionalgovernment,7wereacademics,and2workedfortheWorldHealthOrganisation;

• Region,oneormoreof:England,Wales,Scotland,Ireland,continentalEurope,Canada,Australia,Chile,SouthAfrica;

Workshop:

TheLiverpoolworkshoptookplaceon5&6October,2009,attheForesightCentre.Threemembersof the project team (ASS, DA and SP) led theworkshop through presentations, facilitating groupworkandchairingfeedbacksessions.19outofthe44peopleinvitedwereabletoattend,includingthreemembersoftheAdvisoryGroup.Thelowresponseratereflectsthefactthatinvitationstotheworkshopweresentoutatrelativelyshortnotice,fourweeksbeforeittookplace.Also,wereceivedadditionalfundingtoenableustoinvitemoreoverseasparticipantsmostofwhomwereunabletoattend.ThreeofthosewhocamecouldonlyattendontheMondayandsixothershadtomissoneorbothofthefinalsessionsontheTuesday.

Workshopprogramme(seeAppendixD):

Central to the workshop programme were four group work sessions designed to explore theparticipants’knowledgeandopinionsinthefollowingareas:


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• Groupwork1:StrengtheningequityinHealthImpactAssessment–thelocalcontext;• Groupwork2:StrengtheningequityinHealthImpactAssessment–theglobalcontext;• Groupwork3:EquityrecommendationswithinHIA/HEIA;• Groupwork4:MakingHEIAhappenandmaximisingitsimpact.

Theparticipantsweresplitinto3groups,withadifferentmixfortheMondayandTuesdaysessions.ASSpre‐plannedthegroupssothattherewouldbeanequitabledivisionofpeoplebygenderandexperience.Thethreegroupsmetinseparateroomsandeachwasfacilitatedbyamemberoftheprojectteam.ForGroupwork4,however,thenumberofparticipantswassufficientlyreducedforittobemorepracticalforeveryonetomeetasonegroup.

Afinalsession,“HealthEquityImpactAssessment:towardsaconsensus”,hadbeenintendedtobeagroup discussion to draw some conclusions from the workshop. The number of participantsremaining (10) at this stagemeant that the discussionwould not have been representative of allparticipants. Itwas decided, therefore, for the participants andmembers of the project team toworktogetherandbreakintofivegroupstoanswerthefollowingquestions:

“Whatwouldyouliketosaytotheworldabout:1. EquityinHIA?2. Whatyouthinkshouldhappennext?”

Keymessagesfromthefeedbackanddiscussionfromthissessionhavebeenincorporatedintothefindingsbelow.

Recording:

Allthegroupworkandfeedbacksessionsweredigitallyrecorded.Unfortunatelyoneofthedigitalrecordershadbeen set to recordonlywhenpeoplewere speakingandwediscoveredafterwardsthat this is not suitable for a conference environment as the recorder tends not to record thebeginningandendofsentencesaspeoplespeakloudestinthemiddleofsentences.Consequentlythe group sessionswhere this recorder hadbeenusedhavenot recorded completely. There areenough of the conversations to identify the key points from these sessions, but not enough toextractaccuratequotes.

Alltherecordedsessionsweretranscribed.

RotterdamWorkshop

TheRotterdamworkshoptookplaceattheHIA09conferenceinRotterdam,TheNetherlands,14‐16October.Itwastitled“HealthEquityImpactAssessmentPilotProject”andlastedfortwohours.Theparticipantswereselfselected;astheywereatanHIAconference,theyallhadan interest inHIA,buthaddifferinglevelsofexperienceofHIA.Mosthadaninterestinhealthequity.

Following a brief presentationbyASS and SP, the 20participantswere asked to break into threegroups.Eachgroupwasfacilitatedbyamemberoftheprojectteam(ASS,DAandSP).Thegroupswereaskedtoreflectonthefollowingquestions:

• HowdowestrengthenequityinHIAlocally?• HowdowestrengthenequityinHIAglobally?• EquityrecommendationswithinHIA?• Howtomakeithappen,includingwhetherornotweneedsomethingnew?


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Thegroupselectedsomeonetofeedback.Thefacilitatorstooknotesofthegroupdiscussionsandthefeedbacktothewholegroup.

Analysis

The workshop transcriptions, together with notes from project team members from bothworkshops,weresubjectedtoathematicanalysis.BecauseoftimeconstraintstheanalysiswasnotdoneusingNVivo8,ratheroneauthor(SP)readthenotesandtranscriptsandextractedkeythemes.

Keyfindings

The following themes emerged from the discussions at both the Liverpool and Rotterdamworkshops.

Equity

Theworkshopparticipantswereaskedtoreflectontheinfluencesonequityatthelocal/nationallevelsandattheregional/global levels. Aswellas influencesandactionsspecifictotheselevels,whicharereportedbelow,theparticipantsidentifiedareasofactionandconcernsthatapplytoalllevels.

Thepursuitofequityisessentiallyastatementofvalues;abeliefintheimportanceofsocialjustice.Policymakersarenotnecessarilymotivatedbyequitable,utilitarianvalues. Theirprioritiesmightnotfittheequityagenda;theirpriority,forexample,mightbeeconomicgrowthratherthanhealthandwellbeingofthemany.

Wealthy countries andwealthy people endeavour to protect their own interests. It is difficult tovisualiseinequityinareasphysicallyandculturallyremovedfromwhereweare.Tocounteractthisitisnecessarytobuildaconsensusthatequityisanimportantvalue.Todothisweneedtomakeequity personal to those not considered to be at risk, such as the middle classes and wealthynations. It is importantthatwehighlightthebenefitsofequitytothewholesociety,nationalandglobal.Inordertobuildsuchaconsensusweneedtoidentifytheactorswewanttoengagewith,whattheirpowerbaseis,whattheirinfluencesare.Theseactorswillvaryaccordingtothelocalandnationalcontexts.Whenworkingwithsectorsunaccustomedtoconsideringhealthandequityitisimportantthatweworkwiththeirprioritiesanduse languagethattheycanengagewith. ‘Equity’mightbetoospecific;moreprogressmightbemadeifweusetheterm‘fairness’.

We need a socialmovement and charismatic champions to raise awareness of equity issues andcreatepressureforchangeatlocal,nationalandgloballevels.Championsatthelocalandnationallevelscouldbepoliticians,policymakers,serviceproviders,andcommunity leaders. Atthegloballevelwewouldneedtoengagewithpeopleinpositionsofhighauthority,orwithhighvisibility–inthesamewaythatBobGeldofandBonohavebeenchampionsforthefightagainstextremepoverty,especiallyinAfrica.

The fundamental determinant of inequities is the distribution of power. Powerful elites controlresourcesandmakepolicies. Weneedtoidentifyandengagewiththosewiththegreatestpowerandinfluenceinordertoadvocateforhealthequity.Inordertodothisweneedtorecognisethatdifferentgroupsoperateindifferentways,usedifferentlanguage,andhavedifferentvalues.


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Theparticipantsemphasisedthecontextualnatureofequity.Therearedifferentpatternsofequitywithin countries and in different parts of the world; the European stepwise gradient in healthdeterminantsandoutcomesdoesnotapplyinallcountries.Equallythedeterminantsofhealthvarybycountry;genderinequalities,forexample,haveamuchgreaterinfluenceinsomeareas.Policiesandrecommendationshavetobesensitivetothesepatternsandtothepolicyandsocialdynamicsthatcreateandre‐createthem.Thedistributionofpowerwillvarybycountry,andthiswilllimitthetransferabilityofresearchfindingsonimprovinghealthequity.

Theworkshopparticipantsraisedconcernsaboutaccountabilityandtheconstraintsthataccompanyaidtopoorercountries.Althoughtheseissueshavebeenexpressedasinternationalconcerns,therearealsoparallelsatthelocal/nationallevels.

Eventhoughphilanthropists,suchasBillGates,areprovidingmuchneededfundstotackleseriouschallenges to health, they are not accountable to anyone for their actions. At the local level,powerful groups and organisationsmay engagewith communities in order to promote their ownagendas,ratherthanforthebenefitofthosecommunities.Conditionsattachedtoaidmaypromotethe donor country’s products. Vertical health programmes can undermine the development ofhealth systems. And multiple programmes from multiple donors may be uncoordinated, notaccountable to a single organisation, and time spent reporting back to multiple donors candrasticallyreducetheamountoftimethatcanbespentondeliveringthepoliciesandprogrammeslocally.Together,theselimitacountry’scapacitytocopeandbeautonomous.

At the local level,many participants expressed concern at the unintended consequences of arearegenerationprogrammeswhere theoriginal inhabitantsaredisplacedas areasare improved: forexample:

...therewasaproject to cleanupan informal settlement,because itwould flood regularlythere,and[therewere]highratesofinfectiousdisease,etc.Andthepeopletheresaid,whatareyoudoing?Youcleanthisup,we'renotgoingtobeabletoaffordtherent ... it's rightnexttowherewelive,wecantellwhenit'sgoingtoflood,wejustmoveourstuff.It'sfineforus,don'tmuckitabout,please.Andthen,sureenough,itwasimprovedandeverybodyhadtomoveout.Andit'snowmuchmoreexpensivetolivethere.

Sheffield has rebuilt itself in terms of housing and that sort of thing. But what tends tohappenisthatyouthengetbetterqualifiedandricherpeoplecomingin.Andwhatyoudon'tgetistheactualpeople,whowerethethirdgenerationunemployed,doinganybetteroutofthedealatall.

Itwould be useful to have examples ofwhere the original inhabitants havebenefitted fromareaimprovements.Equally,itwouldbeusefultounderstandwhichpeopleendupinpoorhousing,forexample,andwhy.

There was also concern about the unintended consequences of national health protection andimprovementprogrammes.Theexamplegivenwasthatofreducingsmokingrates.Thereductionofsmokinginrichercountriescanhaveeconomicimplicationsforcommunitiesinpoorercountrieswheretobaccoisgrownasacashcrop.Thesecommunitiescouldlosetheirlivelihoods.Astobaccoconsumptionisreduced,thesecommunitieswillneedhelptoidentifyandproducealternativecrops.


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Thereareopportunitiesforpromotinganequityperspective.Currently,theCSDHandtheMarmotReviewonhealthinequalitiespolicyinEnglandhaveraisedawarenessofthesocialdeterminantsofhealthandhealthequity.ThesecreateanopportunitytoraisetheprofileofhealthequitywithintheUK. Policyopportunities cancome fromresponses tobothnaturalandman‐madecrises, suchasextremeweatherand thebankingcrisis, respectively. At theglobal level, tradenegotiationsandclimatechangetalkscreateopportunitiestoraisehealthequityasanissuetobeconsidered.

Ratherthan“HealthinallPolicies”,weneedtopromote“EquityinallPolicies”.

Thenextsectionsconsiderinfluencesonequityinthelocal/nationalandregional/globalcontexts.Workshop participants stressed that local–national–global interactions are not linear and arecomplex,andtheyarecharacterisedbypowerimbalances.

Equityinthelocal/nationalcontext

Atthe local/national level,action isconstrainedbypersonalandpoliticalvalues. Individualsandgovernmentsneedtobesympathetictotheidealsofsocialjusticefortheretobetherightcontextwithinwhichequityimpactscanbeassessed.Thepoliticalcontextisfurtherdefinedbyshort‐termpriorities,whichcanleadtoconsiderationssuchaseconomicgrowthbeinggivenhigherprioritythanequity.Thedegreeofdemocracyandfreedomwithinacountrywilldeterminetheextenttowhichcivil societywillbewillingtocreatepressureforchange; if theyare fearfulof retributiontheyareunlikelytospeakout.Inadifferentway,communitiesincountrieswithhigherlevelsofdemocracy,such as theUK, that have felt excluded for generationsmay feel disenfranchised andnot engagewithdemocraticprocesses.Insuchcircumstances,andinemergingdemocracies,itisimportanttoencourageandsupportpeopletovote,especiallytheyoung.

Oneparticipantcommentedthatemphasis isusuallyplacedonengagingwithdecisionmakersandcommunitiesintermsofgeneratingtop‐downandbottom‐uppressureforchange.Therecanbetopandbottom level commitment tochangebutpoliciesget interpreted inconsistently in themiddle,however.Thismayreflectthedifferenthistoricalcharacteristicsofdiverseareas,organisationsandgroups.Tochallengethisweneedchampionsforequityinkeypositions,andtosupportthemiddlelayerbytheprovisionofskillsandthecreationoflocalnetworks.

Workshop participants identified the following positive influences on health equity at the local /nationallevel:

‐ Socialdemocracy–includingtheredistributionofmoneyandservicesforsocialjustice;‐ Stronguniversalprogrammes;‐ Progressivetaxsystemsandsocialprotection;‐ Strongcivilsocietyorganisations:

o We need people empowered to demand their rights and / or to ask the rightquestionsofpolicymakersandimplementers;

o We need people – civil society groups AND professional groups – empowered toengagewitheachotherandfindcommonground;

o Weneedtorecogniseandsupportcommunityresilienceandpersonalresilience.

Participantsalsoidentifiedthefollowingnegativeinfluencesonhealthequity:‐ Marketfundamentalism;‐ Powerandresourceinequalities:


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o Distributionofpower,money,andresources,o Inequalitiesinstructuraldeterminantsofhealthandhealthinequalities,o ThepersonalchoiceagendaintheUKmayexacerbateinequalities;

‐ Theriseinneo‐conservatism;‐ Economicreductionism;‐ Ahealthdiscoursedominatedbybiomedicineandbehaviourchangeapproaches,

o Statecontrolofthemedialimitsdebatesandtheprovisionofinformation.

Locallevers/driversofactiontoimprovehealthequityincludetransportpolicy,landuseplanning,housing policy, local taxation, environmental regulations, business zoning, local governmentprocurementpolicies.Thewaysinwhichpublicservicesaredeliveredmayhaveapositiveeffectonhealthequity. Equitycouldbeenhanced if thedifferent sectorsareable toco‐operatewitheachother and engage effectively with communities. This could be supported by local flexibility inmanaging resources, although this can be limited by the political context and global pressures.Therewouldhavetobeeffectiveaccountabilitysystems,andmonitoringandevaluationofservicestoassesstheirhealthequityimpacts.

Equityintheregional/globalcontext

Theworkshopparticipantsobservedthattheregional/globalcontext ismoresophisticated,morestructured and hierarchical, uncontrolled and uncontrollable, covert in its operations andcharacterisedbycomplexinteractions.

Workshopparticipantsidentifiedthefollowingnegativeinfluencesonhealthequityattheregional/globallevel:

‐ Alackofcommonvaluesand/orgoals.‐ Powerinequalities,includinggenderinequalities;‐ The influenceofnationalgovernmentsthroughforeignpolicyandmilitaryspending. Also,

because national regulatory systems are at different stages of development, and becausethere are different degrees of political commitment to social justice, there are differentdegreesofsocialprotectionandregulationofemploymentconditions.

‐ Changesinlocalidentitiesthroughthespreadofthecultureofcountriesandorganisationsthatdominateglobalpoliticalandeconomicpower, forexamplereplacingtraditionaldietswithfastfoodslikeMacDonald’sandhighsugardrinkslikeCoca‐Cola;

‐ Theglobalcapitalistmovement,representedby:o Financial systems:Unregulated financialmarkets; the existence of derivatives; the

activityof investmentbanksandprivateequity firms;off‐shore financial centres–“taxhavens”;theeliminationofmoralhazards–forexample,thetaxpayerbailoutof failedbanks removes the incentive for thoseorganisations tobehave inamoreresponsibleandequitableway;

o Liberalisationoftrade–tradeisseenasanendinitself,ratherthanameanstoanend. This isparticularlydamagingforhealthequity inthetradeof: food,tobacco,alcohol,thedisposalofhazardouswaste;

o Theactivityofdrugcompaniesthatplaceprofitoverthehealthandwellbeingofthepeopleinneedoftheirproducts–especiallythoseinpoorercommunitiesandpoorcountries;


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o The growth of public / private partnerships and the role of transnationalorganisations in the formulation of global policy, leading to the increasedprivatisationofhealthcareandthemovementofheathcareworkers frompoorercountriestoricherones;

‐ Theinequitabledistributionofthegainsfromandexploitationofnaturalresources,suchaswater,oilandminerals.

‐ Climatechange;thegrowingofcropsforbiofuel–ratherthanforfood‐andthedestructionofnaturalhabitatstodoso.

‐ Populationgrowth–longerlifespansneedgreaternumbersofyounger,workingagepeopletosupportageingpopulationsthroughtaxation. This isunsustainable. It is leadingtotheleasingoflandintheglobalSouthbycountriesintheglobalNorthinordertogrowfoodtofeedtheirpopulations.ThismaylimittheabilityofcountriesintheglobalSouthtobeself‐sufficientinfoodproduction.

Participantsalsoidentifiedthefollowingpositiveinfluencesonhealthequityattheregional/globallevel:

‐ RegionalagreementsbetweenmiddleincomecountriestopoolresourcesandsupportthroughlocalfinancialorganisationssimilartotheIMF;

‐ TheG8hasbeenexpandedtoincludemorecountrieswithdevelopingeconomies,creatingtheG20;

‐ Globalhealthdiplomacy–“multi‐levelandmulti‐actornegotiationprocessesthatshapeandmanagetheglobalpolicyenvironmentforhealth”(WHO).

‐ NGOsraisingawarenessofhealthequityintheiractivitiesandpartnerships;‐ Someforeigninvestmentcanleadtobetterworkingconditionsinpoorercountries;‐ TheactivitiesandleadershipofWHOandtheUN.

HIAorHEIA?

Theworkshopparticipantswereclear that there isnoneed foranewHEIAmethodology. HIA, intheory, includes theconsiderationof inequalities / inequities, although theparticipants felt this isoftenmorerhetoricalthancompletedinpractice.Thechallenge,therefore,istoimprovetheequityfocus of existing HIA methodologies. Challenges to this come from the multiple and complexinfluences on health equity, described above, and the fact that interpretation of HIA is contextdependent;weneedtotakeaccountofthe3Cs:context,cultureandcapacity.

HowdoweimprovetheequityfocusofHIA?

Firstly, the workshop participants noted that equity is most often addressed in HIA through theassessment of potential differential impacts on vulnerable groups or other population subgroups.However,equitywithinHIAisnotjustdifferentialanalysis;thereisalsotheneedtounderstandthegap between policy development and implementation, and the ways in which this generatesinequity.Theseprocesseswillbecontextdependent.

It is good practice in HIA to involve stakeholders in the process, including those from affectedcommunities. Therewassomediscussionofhowwecharacteriseand interactwith communities.Theparticipantsobserved that,aspractitioners,wemightcharacteriseacommunity inanegativewaybut that local residentsmaynotexperience it asabadplace to live. It is important thatwerecognisethatdifferentcommunitieshavedifferentcapacities:


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‐ tobeheardandhaveinfluence,withdifferenttimeframesforchange;‐ to manage devolved funding, and these differences in capacity could contribute to the

wideningoftheinequalitiesgap.

We, therefore, need to develop ways of engaging with all communities regardless of theircapabilities.

TheworkshopparticipantsstressedthatequityinHIAisdifficulttodo.ExperiencefromtheuseofEFHIA demonstrates that policy makers find it difficult to understand the social determinants ofhealthinequity.

OpportunitiesforstrengtheningtheequityfocusofHIA

AcknowledgetheContext

The participants noted that HIA practitioners need to acknowledge the different contexts withinwhichHIA is being implemented. The priorities in theUK, Africa and China, for example,will bedifferent.TherewillbedifferentlevelsofcapacitytoHIA,anddifferentculturalunderstandingsofhealthand itsdeterminants. Englishequity languagemaynot translate intoother languages,andtheequityterminologyitselfmaynotbeunderstoodindifferentcontexts.HIAmaynotbethemostappropriatemethodologytoassessequityimpactsinsomecountries,likeChinawherethepriorityistounderstandpolicydrivers.HIApractitionerscanthenbeadvocatesofassessingequity,butassistinidentifyingthemostappropriatetoolforthosecircumstances.

Advocate

HIA practitioners can advocate for the inclusion of equity in HIA through promoting examples ofgoodHIAswithanequityfocusthathavealreadybeendone,andthroughtheinclusionofequityintheir ownwork. There is a need to promote the inclusion of equity in the practices of powerfulglobalinstitutions,andmakethemaccountablefortheiractionsthataffectequity,andpromotetheinclusion of equity considerations in both HIAs commissioned by developers and in other impactassessmentmethodologies, such as the International Finance Corporation guidelines. Generate /facilitateglobalconversationsabouthealthequity,usingexistingnetworksandpublications;includeorganisations such as the IAIA, WHO and PAHO. Advocate for health equity amongst politicalleaders and stakeholders; use stories to highlight the issues and help them to learn the equitylanguage.PromotetheroleofthehealthsectorasanadvocateforhealthequityandHIA.MostHIAactivityisintheglobalNorth,solistentotheglobalSouth.

Process

ParticipantsfeltthattherewasnoneedfornewHIAtools.InsteaddifferentaspectsofHIAcouldbeemphasisedfordifferentfoci(equalities,mentalwellbeing,andsoforth);soitisimportantthattheHIApractitionerisclearaboutwhattheHIAisintendedtoachieve–includingtheequityfocus.Usedifferenttoolsfordifferentaudiences.PromotetheuseofequitywithinHIAbychoosingtopicswithgoodnewsoutcomes. Includethepolicycontext intheHIA– it ispossibletocritiquethecontextwithout being negative about the policy, and this will help to reduce resistance to the process.Emphasisethepositiveoutcomesofthepolicy.NegotiationisanimportantpartoftheHIAprocessbecause it can reduce the potential for conflict and help to build understanding. HIA should beintroducedatthestartofthepolicyprocessandequityshouldbeincludedinthebeginningofthe


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HIAprocess–toactasahookforthewholeHIA.Involvestakeholdersfromthestart.HIAneedstohaverecommendationswithanexplicitequityfocus.

HIAisoftentalkedaboutasifitistheassessmentitselfthatchangespolicies;weneedtorememberthatHIAisapathtowardspolicychange.HIAcanmakeadifferencetohowpeopleconsiderhealthequitybutitneedstoberecognisedaspartofabiggerprocesstoevaluatetheimpactofpoliciesonhealthequity.Itcanhelptoidentifythecausalchainofinfluencesonhealthequityfromthelocalcontextupwards.

Quality

WorkshopparticipantsarguedfortheneedtodevelopqualitystandardsforHIAatallgeographicallevels. There shouldbe aminimumsetof standards thatwouldhave tobe signedoff, along thesamelinesasEnvironmentalImpactAssessment.WeneedalevertomakeHIAmandatory.

Thereisaneedforcapacitybuildingtoassessandaddresshealthequityimpacts;notjustthroughHIA,althoughHIAhasaroletohighlighttheneedtoassesshealthequity,andlookforwaysofdoingso,inregionswherethereiscurrentlylittlecapacitytodoHIA.HIAtrainingshouldfocusonhowtotakeequityintoaccountinHIA.ThereisscopetobuildglobalcollaborationstodevelopcapacityforHIAtraininginregionswherethereisstill littlecapacitytodoHIA;andgeneratelearningnetworksforHIA.

It is crucial thatmoremonitoring of the outputs fromHIA takes place; in terms of the uptake ofrecommendationsfromHIA,theimpactofHIAonpolicydevelopmentandimplementation,andthemonitoringoftheimpactsofpolicyonhealthequity.

LimitationsontheinclusionofequityinHIA

Context

ThelackofpoliticalcommitmentandlegislativebackupwilllimittheconsiderationofequitywithinHIA.Theinclusionofequitycanbeperceivedasacriticismbynon‐healthsectors,soitcanbeeasierto engage them in anHIA that focusesonpopulationhealthoutcomesalone. A fewparticipantsobserved that HIA reports can be left in limbo or reduced in scope due to changes in the publicsectorstaffparticipatingintheresearch(throughrestructuringorindividualleaveofabsence).

Workshop participants wondered who would conduct global HIAs: theWorld Bank?WHO? IMF?UN?Alltheseorganisationsareconstrainedbytheirfundersandpartners,sowhowouldbeabletoindependentlyassesstheimpactofglobalpoliciesandsystemsonhealthequity?

Process

HIAsofglobalpolicieswillneedtoassesstheirimpactonpowerimbalances–powerimbalancesarenotwidely understood as a determinant of health inequities; HIA is currentlyweak in addressingissuesofpowerandpowerinequalities.LocalHIApractitionersarenotasgoodastheycouldbeinraisingdifficultquestionsandchallengingpolicymakers.TheHIAprocessrepresentswhite,middleclass systems and values and as such can be alienating to local population groups, especiallyindigenous groups. Community engagement is key to the success of HIA and as such local HIApractitionersneedtobeconsciousofthewaysinwhichtheyengagewithcommunities.


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Recommendations

TheworkshopparticipantsnotethatHIAisoftenjusttheappraisalprocessanddoesnotincludethemappingofthelocalcontext,nordoesitmakeeffortstogainownershipoftherecommendations.Politicaltimeframes,financesandotherresourcesdeterminewhichrecommendationsgettakenup;themoredifficultonesmightbedropped.

Evidence

A recurring theme throughout the workshops was the importance of available, accurate anddifferenttypesofevidence.

Theparticipantsindicatedthatthereisaneedformoredetaileddataatthelocallevel,andbetternational level indicators. Theavailabilityofdata is country specificwithgenerally goodaccess todata inhighandupper‐middle incomecountriesandpooravailabilityofdata in lower‐middleandlowincomecountries,whichmightnothavethestructuresinplacetogatherrobustlocalleveldata.Different countries also have different population structures and different priorities, which willaffectthetypesofdataneededforHIA.

ThereisgenerallyalackofrobustevidenceforHIApractitionerstodrawupon.Andthereisapoorevidencebase for the impactof upstreamdeterminantsonhealthequity, especially at the globallevel. This forcesa focusondownstreamdeterminants,andaretreat to thebiomedicalmodelofhealth.

Evidencecanbediscountedwhereitdoesnotfitwiththepoliticalaimsofpolicymakersorthevaluesystemsofdifferentsectors.Thesevaluesystemswillleadtoonesortofevidencebeingprioritisedover others; quantitative evidence usually dominates. There is an assumption that economicevidence cannot be challenged, but it can be flawed. Although there are economists that argueagainstdominantmacroeconomicpracticestheirvoicesarenotheardbecausewhattheyaresayingdoesnotfitwiththeinterestsofelitepowerfulgroups.HIApractitionersaregenerallynotgoodatbreakingdownsuchbarriersandchampioningothersortsof‘soft’evidence.

Impact assessment models that are based on reductionist, cost‐benefit analyses are likely toproducesimplisticassessmentsthatdonotaccountforlocalneeds,contextsandimpacts.Abreadthofevidenceisrequired,includingsocialscienceresearchandnarrativesfromthosemostlikelytobeaffected. These stories can be powerfulways of engagingwith policymakerswho, research hasshown,oftenmaketheirdecisionsbasedonpassionratherthanlogic.Thereisaneed,therefore,forbothhardevidence(quantitativeandqualitative)andstories.

Often evidence from different sources is blended together in HIA reports. This is problematicbecause this evidence will have originated from sources with very different value systems. TheevidenceinHIAshouldbepresentedinsuchawayastomakethesevaluesystemstransparentandenableparticular interestsandissuestobehighlighted.Therelativeweightingofevidencerelatingtovulnerablepopulationsandtheareacharacteristicsofwheretheylivewillbedeterminedbytheobjectivesofthepolicybeingassessed.

It is important thatHIA isseentoberobustandthat thevaluesystemsunderpinning itaremadeexplicit. Itwould enhance the reputation ofHIA if itwere peer‐reviewedby potential criticswithknowledgeofresearchrigour,especiallythoseideologicallyopposedtoit.


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Research

Differentareasofpotentialfutureresearchwereidentifiedbytheworkshopparticipantsthroughouttheworkshopdiscussions.Thesesuggestionsaresummarisedbelow.

Pilotstudies:

‐ Takeanequityissueandmapallthecurrentandhistoricalinfluencesonthatpolicyfromthebottomtothetop–mapthenetwork, identifythekeyplayers,andidentifythekeypolicyinfluences.

‐ Toaddressrootcausesofhealthinequalities,includingimmigration,tradepolicyandclimatechange,innationalandtransnationalcontexts.

‐ Internationalcollaborationstopilot,testandproducehighqualityHIAswithanequityfocusthatcanbeusedasexamplesofwhatcanbedone–takentodifferentcountrysettings,nottocriticise,buttodemonstratetheaddedvalueofconsideringhealthequity.

‐ IntheGlobalSouth.

Casestudies:

‐ To understand the processes, behaviours, cultures and opportunities of working withmultinationals.

‐ Toseehowelsewemight judge long termhealth inequalities impacts,beyond theuseofmortalityfigures.

Processresearch:

‐ HowandwhenisHIAusedinthepolicyprocess;towhatextentdoesHIApromotealastingunderstandingofhealth(equity)influencesandpolicyimpactsonhealth(equity).

‐ IdentifytheenablersandbarrierstotheimplementationofHIArecommendations;‐ Identify key points on the equity causalweb and examinewhat facilitates and constrains

action on equity at those points and how the people at those points understand thelanguagearoundequity.

‐ Policy ethnography (ethnographic methods to explore the local processes of policyimplementation) to understand the local commitment to equity and the facilitators andconstraintsthatpeopleexperienceinactingontheircommitmenttoequity.

‐ Policyethnographytoexplorethelanguagethatpolicymakers,practitionersandcommunitymembersinanareausetotalkaboutequity.ThisknowledgewillhelptofacilitateabroaderengagementaroundequitywithinHIA.

‐ Equity languagecanbeabarriertocollaboration–getfundingtocreatea languageaboutinequities that works across all sectors – businesses, countries, IAs, health sector, etc ‐recognising that equity / inequity, equality / inequality, deprivation, vulnerability are allcontestedconcepts

Mapping:

‐ Mapthecausalnetworks,andupstreamprocesses.Theworkshopparticipantshighlightedtheneedforevidencetounderstandandtomapthecausalpathways linkingactivityat theglobal level (suchas tradeagreements)withhealthoutcomesatthelocallevel.Althoughsomefeltthiscouldbedauntingforpeopleatthelocal


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levelbecausethecomplexityoftheglobalcontextanditsinteractionwithnationalandlocalprocesses make its influences difficult to unpick at the local level – it can seem too farremovedfromlocalaction.

o This could result in a generic methodology that could be adapted for differentcountries. Someof this isbeingdeveloped from theworkof theCSDHknowledgenetworks.

o Forlow‐andmiddle‐incomecountries,wheredataisscarce,itwouldbepossibletoextrapolate from what is known in the EU. This could be achieved by bringingtogether people with good inside knowledge of a country to debate how thoseconditionsmightworkinthatcontext.

‐ Mapthekeyactors:Whoarethey?Whatbusinessesdotheydo?Whataretheirprocesses?Howdotheyinteractwithcommunities?Whatpressuresaretheyunder?

‐ Mappotentialfundersforfutureresearch.

Summary

Theworkshopdiscussionsstressedtheimportanceofraisingawarenessofequityandhealthequityatthelocalandgloballevels.Therewereanumberofcommonconcernsandobservationsatthesedifferentlevels.Firstly,thataconcernaboutequityreflectsaparticularsetofvaluesthatprioritisesocial justice,but thesevaluesarenot shareduniversally. So, there is aneed to raiseawarenessabout the importance of equity through international collaboration, social movements and theidentification of champions with influence in their particular arena (global, national, local orcommunity).

Power imbalances are at the root of social inequalities, these power differentials need to beacknowledged,exploredandaccountedforwithinHIA.Thereisaneedforgreateraccountabilityofactivity andactions that affect equity at all levels. Thoughtneeds tobe given to theunintendedconsequences of policies – there may be global consequences of national action, such as themigrationofhealthcareworkersandthedamagetothelivelihoodsofpeople inpoorercountries;there may also be consequences locally where poorer residents may be displaced due to areaimprovements.

Currentlythereareopportunitiestoraiseawarenessofequityinlocal,nationalandglobalspheres.

Atthegloballevelequitycanbedamagedbythingssuchas:alackofcommongoalsandvalues,thedistribution of power, the impact of national governments, the spread of unhealthy culturalidentities, climate change, and the inequitable access to and exploitation of natural resources.There are indications that there is a growth in awareness of equity globally, however. Morecountries have been invited to join the G8 (making the G20). There is growing regionalcollaboration.TheleadershipofglobalorganisationssuchasWHOandUNcreateanopportunityforraisingawarenessoftheissues.

TheparticipantswereclearthatthereisnoneedforanewHEIAmethodology.Theyalsofeltthatthere are sufficient tools available within HIA to assess equity. These could be better applied,however,andthereisarealneedtostrengthentheconsiderationofequitywithintheHIAprocess.Equity is rarely consideredwithinHIA, andwhere it is done equity is equatedwith assessing thepotential differential impacts of policies on vulnerable groups. Weneed tomove beyond this to


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consider what the causes of inequalities are and the ways in which policy affects socialdeterminants,perpetuatinginequalitiesinaccesstoresources,includingpower.

OpportunitiesforstrengtheningtheequityfocusofHIAcomethroughacknowledgingthatHIAandhealth equity are context specific; advocacy and building collaborations to assess and promotehealthequity;recognisingthatHIAispartofabiggerprocesstoassesstheequityimpactsofpolicy;andtakingstepstoimprovethequalityofHIA.Withregardstothelatter,thereisaneedtobuildcapacitytodoHIAandto incorporateequitywithinHIAtraining;HIAwouldbenefit fromhavingaminimumsetofstandardsthatcanbeappliedinallcontexts;anditisessentialthatHIAandpolicyimpactsaremonitoredandevaluatedfortheireffectsonhealthequity.

Limitations to including equitywithinHIA come from a lack of politicalwill, and powerful groupsprotecting theirown interests. It isnotclearwhowouldbesufficiently independent todoequitybasedHIAsofglobalprocessesandpolicies.Inadequatemethodsfordealingwithpowerimbalancesisanotherlimitingissue.Locally,timeandresourcepressureswillconstraintheuseofequitywithinHIAandwillinformwhichrecommendationswillbeactedupon.

A clear common thread throughout these discussions was the need for available, accurate anddiverseevidencetosupportHIA.Theprioritisationofevidenceisvalueladen,anditisnecessaryforHIApractitionerstopromotetheuseofabroadrangeofevidence, inthefaceofoppositionfromgroupswithdisparatevaluesystemsanddifferentpriorities.

Finally, several opportunities for research have been identified to further the understanding ofinfluences on health equity, identify key actors and processes in the distribution of power anddeterminants of health, understand the constraints on action to improve equity, and tomap thecomplexcausalwebsthatarethe‘causesofthecauses’ofinequity.

Participantsconsideredthatthisprojectconstitutesawake‐upcallthatequityandequalityneedtobeconsideredbetterinHIA.ItwasarguedthatweneedastrategyforincorporatingequitybetterinHIA.Thisprojectcouldmapthatstrategy,anddeveloparoutemaporplanforwhattodonext.

HEIA scoping project Discussion

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6:Discussion

MargaretWhiteheadhas identified fourcategoriesofaction to tacklesocial inequalities inhealth:strengtheningindividuals,strengtheningcommunities,improvinglivingandworkingconditions,andpromotinghealthymacro‐policies(Whitehead,2005). HIAcurrentlyhasthecapacitytocontributetothefirstthreeofthesecategories.HIAcanbeatoolforempowermentforbothindividualsandcommunities,whereindividualsandgroupsareactivelyinvolvedintheHIAprocess.HIAcanhelptoimprove living and working conditions by identifying potential negative impacts and enhancingpotential positive impacts of policies and programmes, and differential assessment of potentialimpacts on vulnerable or other population subgroups makes a contribution to the reduction ofinequalitiesbetweengroups.However,thefourthcategoryofpromotinghealthymacro‐policiesislargelylackingfromHIAasitstands.Butitisthisthatthisprojectchieflyaimedtoaddress.

This project set out to assess the extent to which equity is currently incorporated into HIA, toexplorewaysof assessing the impactsofmacropolicy (upstreamdeterminants) onhealthequity,andtodeterminewhetherornotthereisaneedforanewHEIAmethodology.

ItwasclearfromboththeinterviewsandworkshopsthatparticipantsfeltthatthereisnoneedforanewHEIAmethodology.ThereareexistingmethodologiesandtoolsthatarecapableofconsideringequitywithinHIA. All three researchphasesof thisprojectconcludedthatequity isnotcurrentlyassessedadequatelywithinHIA,andsodiscussionsturnedtohowthiscouldbestrengthened.

The scoping review demonstrates that there are nowmore guidelines with an explicit equity orinequalitiesfocus.OftheHIAsthatassessequityimpacts,mostdosothroughexaminingpotentialdifferentialimpactsforvulnerable/disadvantagedgroupsorotherpopulationsubgroups.Intruthmost of these assessments are not assessing equity as defined here – as avoidable and unfair orunjust differences. Only the EFHIA guidelines and assessmentsmade any attempt to include thisqualification,andpractitionersusingtheseguidelinesobservedthattheassessmentofavoidabilityandfairnessaddsalayerofcomplexitytotheHIAandsomaynotbedone.

In addition,manyHIAs talk aboutequityor inequalities in their complexitybut then focuson the‘do‐able’,assessingdifferentialimpacts.EventhoseHIAswithastrongfocusondifferentialimpactsoften do not discuss their findings and recommendations in terms of their impact on equity orinequalities – even though the recommendations may come out of a deep consideration of theimpactsonequity,theyarefrequentlynotpresentedinthislight.

There are two concerns here. One is the lack of definitions of equity terminology within HIAs.Withoutdefiningthisessentialterminology it isdifficulttoassesswhetherornotthepractitionersintendtoapplythevaluesofavoidabilityandfairnesstotheresults.Theotheristhebasicquestionofwhetherornotassessingequity isthesameasassessingthepotential impactsonvulnerableordisadvantagedgroups. HilaryGrahamhas identifiedthreestrategiestoreducehealth inequalities:focusingpoliciesandprogrammesonthedisadvantage;attemptingtonarrowthegapbetweenthepoorest groups and either the richest or the national average; attempting to reduce the socialgradient in health outcomes (Graham, 2004). Although addressing the gradient is the hardestoption, it isalsotheoptimalone(Graham,2004). There isevidencefromthisresearchthatsomeHIApractitionersagree thatequity ismore thanaddressing thehealthconsequencesofpolicy for


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vulnerableanddisadvantagedgroups.Aconsiderationofequityalsoneedstoconsiderthe‘causesofthecauses’ofdifferencesinhealthstatus,whichechoestheaimsofthisresearch.

FindingsfromallthreeresearchphasesemphasisethattheinclusionofequitywithinHIAiscomplex,resource intensive, challenging methodologically and time consuming. For these reasons it wasarguedagainstinstitutionalisingHIAwithanequityfocus.Rather,thesuggestionisthatHEIAshouldbedoneoncarefullychosentopics,offeredasexamplesofwhatcanbedone.

There were several recurring themes across the data collected. Firstly, the inclusion of equityconsiderationsinHIAreflectsaparticularvaluesbase;onethatprioritisessocialjusticeandfairness.Thesevaluesarenotuniversalandmaynotbesharedbytheinstitutionsandorganisationswhosepolicyandpracticewewouldwishtoassessforitsimpactonhealthequity.ThishasimplicationsforhowHIApractitionerswouldengagewith these institutionsandorganisations, for theneed tobeexplicitaboutthevaluesunderpinningHEIA,fortheneedtoworkcarefullytofindcommonlanguageor to find ways to translate health equity language into terminology that can be understood bydifferentaudiences,andforthetypesofevidencethatwouldbeacceptableinthesecontexts.HIApractitionersneedtobeadvocatesfordifferenttypesofevidenceandforequityitself.

Secondly, the determinants of health equity, the patterns of equity, and the social and policyinfluencesonhealthequityarecontextspecific.Thesewillvarywithinandbetweencountries.HEIAneedstotakeaccountofthesedifferences.Also,theEnglishequitylanguagemaynottranslateinameaningfulwayintootherlanguages,andthismaylimitthetranslationoftheconceptsandvaluesunderpinningHIAintoothercultures.

Thirdly,the‘causesofthecauses’ofhealthequitywereclearlyidentifiedatalllevels,globaltolocal,as including the influence of financial regulation and practices, and inequalities in power. HIAcannotcurrently incorporateconsiderationof the impactsofdifferentials inpower;participants inthisresearchidentifiedanumberofresearchapproachesthatcouldhelpmappowerdistributions.Participantsarguedfortheneedforaccountabilitysystemsforactionsatthegloballevelthatimpactonequity.O’KeefeandScott‐Samuel(2010)suggestthatHIAcanbepartofsuchanaccountabilityframework,usingtheoperationsoftheInternationalMonetaryFundasanexample.

Fourthly,wecanstrengthentheconsiderationofequitywithinHIAthrough:• capacitybuildingtodoHIAandemphasisingequitywithinHIAtraining;• learningnetworkstobuildandsustainthecapacityforHIAandHIAtrainingglobally;• introducingaminimumsetofstandardstobeappliedtoallHIAsandforthosestandardsto

beenforced;• ensuringthatHIAisrobustandofhighquality;• evaluation andmonitoring of the uptake of HIA recommendations, and of the impact of

policyonhealthequity.

SomeparticipantsstressedthattheassessmentofequityimpactsdoesnothavetobelimitedtoHIA.Infact,HIApractitionerscouldhelpidentifyothertoolsandmethodologiesforuseincontextswhereHIAmaynotbeappropriate.

Finally,thereareseveralmechanismsbywhichhealthequitycouldachieveahigherprofile:useHIAtoraiseawareness;encouragethehealthsectortoraiseawarenessofandsupportinterventionsto


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improvehealthequity;actionbycivilsocietyandhighprofilechampionscouldcreatepressureforchange;takeadvantageofopportunities,orpolicywindows,to introduceequityandhealthequityintotheconsciousnessoftheorganisationsandinstitutionsthathaveaninfluenceonequity.

Thehourglasseffect

Theinterplaybetweenthehistoricaldevelopmentofpolicy,thepolicyimpactsonhealthequityandsocialpressuresforchangecanbeconceptualisedintermsofanhourglass.

In one rotation, the hourglass shows howmultiple factors and developments,includingdominantcultureandideology,overtimeleadtothedevelopmentofaspecificpolicyorpolicyperspective; this thenhas impactsthatspreadoutoverdifferent populations. The policy implementation occurs at the waist of thehourglass,withthehistoricaldevelopmentsaboveandthe impactsbelow. HIAtypicallyoccursatthepointofimplementationanddoesnottakethehistoryofthepolicydevelopment intoaccount. Findings fromthis researchhighlight theneedtounderstandtheinfluencesrepresentedbythetopbowlofthehourglass

inordertofullyunderstandtheequityimpactsrepresentedbythebottombowl.Theimpactswillbemore than thedifferential impactson identified vulnerable groups. Theymay include reinforcingsocialnormsandvaluesystems,whichhelptolimitactionontheupstreamdeterminantsonhealthequity.

Inverted,thehourglassrepresentsthepressureforchangebroughtaboutbycivilsocietyactionandchampionsadvocating forhealthequityperspectives. Now,thewaistofthehourglassrepresentsthatpointintimewhenthissocialpressurecoalesces with a policy window or opportunity, such as the report of theCommission on Social Determinants of Health, the banking crisis or HurricaneKatrina, togenerate change. At this timenewperspectivesandvalues canbeintroduced into the policymaking process. Examples of this are the growth inconcernabouttheimpactsofclimatechange;andsocialpressuretocancelthe

debtsofsomeofthepoorestcountriesintheworld,suchashappenedrecentlyforHaitiinthewakeofthedevastationcausedbytheearthquakethere.

Developingastrategy

The economic evaluation of interventions aimed at changing systems requires newways ofthinking: one sensitive to ecological theory, interactions betweenmicrolevel andmacrolevelvariables,non‐linearities,multipliereffects,andthe fact that individualvaluesare shapedbytheinterventionsweseektoevaluateandthecontextsweseektochange. (Shielletal,2008,p.1283)

Participants at the Liverpool workshop suggested that this project could develop a strategy forincludingequitywithinHIA.Thatisperhapsambitiousforascopingstudy;nonethelesstheprojecthasidentifiedseveralwaysinwhichthingscanbemovedforward.

Thereisaneedformultipleconversationstoraiseawarenessandbuildconsensus:


55

• conversationswithintheglobalhealthequitycommunitytoidentifysharedvalues,concernsandactivity;

• conversationswithdifferentactorstoraiseawarenessofhealthequity,suchascommunityrepresentatives,politiciansandglobalactors;

• conversationswith complementary areas that can enhance the equity component ofHIA,suchassocialjustice,environmentaljustice,andhumanrights;

• conversations across different geographies – the context for health equity action isimportant and we need to engage with these different contexts to understand theimplicationsfortheassessmentofequity impactsofpolicy. ParticularattentionshouldbepaidtoengagingwiththeGlobalSouth.

It is these conversations and collaborations that will lead to the development of a strategy topromotehealthequitylocallyandgloballyandtouseHIAaspartofthatprocess.Oneofus(ASS)isalreadyworkingcollaborativelywithcolleaguesinCanadaandWHOwhoarealsolookingtodevelopworkaroundHEIA,andalsoengagingwiththenetworkofWHOCollaboratingCentreswithafocusonhealthequity.

Alan Shiell and colleagues highlight the need develop ways of identifying and exploring complexsystems(Shielletal,2008);ourscopingreviewechoestheirfindings.Althoughthefindingsfromtheworkshopsandtheinterviewswerecontradictoryastowhetherornotthereisaneedfornewtoolswithin HIA to assess impacts on equity, collectively they identified several areas of research thatwoulddeepenourunderstandingofthemechanismsthatgenerateinequities.Someofthisresearchwouldbeforfurthermethodologicaldevelopment,andotherstomapthedistributionofpowerandinfluenceinthedecisionmakingandimplementationprocessesofpolicy.Inadditionthereisworktoinvestigateanddevelopconceptualmodelsthatwouldprovideframeworksforunderstandingtheinterplayofthecomplexprocessesandvaluesthatpromoteorunderminehealthequity.

Specifically,thefollowingpossibleresearchareashavebeensuggested:

Processresearch

• Sociological assessments to understand the processes of change at different levels of thepolicyimplementationprocessandpeopleasactorsinpolicydelivery;

• Developmentofnewindicatorsfordemocracyandpowerdistribution;• HowandwhenisHIAusedinthepolicyprocess?TowhatextentdoesHIApromotealasting

understandingofhealth(equity)influencesandpolicyimpactsonhealth(equity)?• IdentificationoftheenablersandbarrierstotheimplementationofHIArecommendations;• Identificationofkeypointsontheequitycausalwebandexaminationofwhatfacilitatesand

constrainsactiononequityatthosepointsandhowthepeopleatthosepointsunderstandthelanguagearoundequity.

• Policy ethnography (ethnographic methods to explore the local processes of policyimplementation) to understand the local commitment to equity and the facilitators andconstraintsthatpeopleexperienceinactingontheircommitmenttoequity.

• Policyethnographytoexplorethelanguagethatpolicymakers,practitionersandcommunitymembersinanareausetotalkaboutequity.ThisknowledgewillhelptofacilitateabroaderengagementaroundequitywithinHIA.


56

• Equity language can be a barrier to collaboration – identification of funding to create alanguageabout inequities thatworksacrossall sectors–businesses, countries, IAs,healthsector,andsoforth:recognisingthatequity/inequity,equality/inequality,deprivationandvulnerabilityareallcontestedconcepts.

Pilotstudies

• Takeanequityissueandmapallthecurrentandhistoricalinfluencesonthatpolicyfromthebottomtothetop–mapthenetwork, identifythekeyplayers,andidentifythekeypolicyinfluences.Thiswouldprovide in‐depthknowledgeof thepolicydevelopmentprocessanditsimpactonhealthequity.

• Assessment of root causes of health inequalities, including immigration, trade policy andclimatechange,innationalandtransnationalcontexts.

• Internationalcollaborationstopilot,testandproducehighqualityHIAswithanequityfocusthatcanbeusedasexamplesofwhatcanbedone–appliedindifferentcountrysettingsinordertodemonstratetheaddedvalueofconsideringhealthequity.

• PilotstudiesareespeciallyrequiredintheGlobalSouth.

Casestudies

• To understand the processes, behaviours, cultures and opportunities of working withmultinationals.

• Toseehowelsewemight judge long termhealth inequalities impacts,beyond theuseofmortalityfigures.

Mapping

• Mappingofthecausalnetworks,andupstreamprocessesofalocalpolicy.• Mappingofthekeyactorsonthatcausalnetwork.• Mappingofpotentialfundersforfutureresearch.

ImplicationsforLiverpoolPrimaryCareTrust

ThisworkhasbeenfundedbyLiverpoolPrimaryCareTrust.Acoreaimofthisresearchistoprovideanoutput thatwill benefit thehealthof thepeopleof Liverpool. Liverpool has longbeen at theforefrontofeffortstoimprovepublichealth:fromthefirstMedicalOfficerofHealthintheearly19thcentury, through the first municipal laundry and the first district nursing service, to the city’sfounding involvement intheWHOHealthyCitiesprogrammeinthe late20thcentury,andcurrentwork combining theeffortsof LPCTand LiverpoolCityCouncil to reducehealth inequalities. ThiswealthofexperienceandhistorymakesLiverpoolanimportantsiteforcasestudiestofurtherourknowledgeaboutthegenerationofhealthequityand inequities intheresearchareassummarisedabove.

TheHEIAProjectTeamwillworkwithLiverpoolPCT to identifyanopportunity todisseminate thefindingsor thisproject in suchawayas to raiseawarenessandgenerate reflectionon thehealthequity impacts of LPCT policies and programmes: for example, a workshop to examine theimplicationsforLPCToftherecommendationsfromtheMarmotReview.LPCTwillbeapartnerinapplicationsforfundingtoconductresearchidentifiedaboveinthesuggestedcasestudiesandpilotprojectsinaLiverpoolcontext.

HEIA scoping project Conclusion

57

7:Conclusion

Inourview,thisprojecthasshedsubstantiallightonthemannerinwhichhealthimpactassessmentmust develop if it is to respond successfully to the new demands placed on it by therecommendations of the WHO CSDH and in the case of England, by the Marmot Review whichfollowedit.Inthissection–whichbuildsontherichanddetailedfindingssummarisedinthisreport– we outline the key lessons learned from the project and where appropriate, makerecommendationsforfuturedevelopmentandaction.

Thedefinitionofhealthequity

Therangeofdefinitionsandconceptsofhealthequitythatwefound isunfortunate, inthat itcananddoes leadto frequentconfusionwhenputtingtheconcept intopractice.This isas true in thecontext of health impact assessment as it is inmore general health equity analysis and research.However, this situation isprobablyunavoidable, given thehistorical specificityof the terminologyused in different agencies and societies: for example, a single term and concept, 'health equity'throughout theWHO; co‐existing concepts of health inequality and health equity in the UK andmainlandEurope;andasingleconceptofhealthdisparitiesintheUS.

What this situation clearly demands is thatwhenever health equity is discussed or employed, thetermsusedshouldbedefinedandshouldbeusedinaconsistentmanner.

Inaddition,theglobalcontextofwhattheCommissiononSocialDeterminantsofHealthcalledHEIAdemandsonesingle,globalunderstandingof theHEIAconcept.Thiscouldbeanexpansionof theGothenburgandIAIAdefinitionsofHIA,toexplicitlyencompassglobalpublicpolicydeterminantsofhealthequity.

Thedeterminantsofhealthequity

Unlikethedeterminantsofhealth,thedeterminantsofhealthequityarethemselvesinequalities–inmaterial, psychosocial and behavioural aspects of the life course and of society. These includeinequalities in incomeandwealth, inpowerandcontroloverhealthand lifechances, inaccess toeducation, information and health care, in social inclusion, in social status and the privileges itbrings, in culture and itsmyriad influences on behaviour and experience.Many inequalities havedeep historical and cultural roots; this requires explicit consideration in HIA methodology. Inparticular, the inequitable nature ofmuch public policy and the non‐participative nature ofmostpoliticalprocessesareimportantdeterminantsofhealthinequity.

Equallyimportantarethemanydifferentlevels–fromindividualtosocietalandfromlocaltoglobal– at which health equity is determined. HIA can and should consider potential impacts at andbetweenalloftheselevels.

Indescribing theneed toacknowledgeandaddressnoveldeterminantsanddimensionsofhealthequityinHIA,wearenotnecessarilyarguingforanimpossiblycomplexHIAprocess.Rather,wearerefiningandextendingtheconceptualframeworkforHIA.ManyifnotmostrelativelylocalHIAswillcontinue largely as at present – though hopefully with an enhanced acknowledgement of localimpacts of global public policies. It is, however, the new context of HIA of global public policiesthemselvesthatwillbemostaffectedbyourrecommendations.

HEIA scoping project Conclusion

58

Inaddition to theoutputs (evidencebased recommendations)ofHIAs,aspectsof theHIAprocessitself also contribute to health equity – these include health awareness‐raising and advocacy,communityparticipation,validationofpopularknowledge,personalandsocialdevelopment.Theseimpactsshouldbeenhancedbytheapplicationoftheknowledgegeneratedbythisproject.

HIAorHEIA?

We share themajority view of our stakeholders and key informants that new terminology is notrequiredfornewvariantsofHIAcapableofaddressingglobalpolicy impactsonhealthequity.Webelievethatthetermhealthimpactassessmentwillsufficetotacklenewglobalchallenges.

MethodologicalimplicationsforHIA

Atpresent,littleaccountistakeninHIAoftheprinciples,processesandpracticesofpoliticalscienceand of policy science. Given their central role in the determination of global health equity, thissituationclearlyneedstochange.NewHIAtoolsarerequiredwhichaddresstheroleofpoliticalandpolicy variables and knowledge in determining health equity outcomes. Thiswill require both thedevelopmentandthepilotingofsuchtools,usingappropriateglobalpublicpolicyprogrammesandprojectsasthetest‐bed.

AlthoughtherewasagreementattheLiverpoolworkshopthatnewmethodologicaldevelopmentsinHIAwereunnecessary,thenatureandrangeof'new'healthequitydeterminantsdescribedaboveinthe review, interview and workshops sections, together with the complexity of their potentialinterrelationships,leadsustoquestionthisconclusion.Attheveryleast,furtherresearchisrequiredtoelucidatethisquestion.

Capacitybuilding

ThetaskofbuildingadequatecapacityforHIA,especiallyintheGlobalSouth,isbeyondthescopeofthis project. However,we are impressed that in thewake of the CSDH report,WHO has alreadymade good progress in initiating international discussions aimed at addressing this task. Theresourceimplicationsintermsofknowledgetransfer,humanandfinancialresourcesare,however,substantial.Their realisationwill in turndependonthepoliticalprioritygiventotherealisationofhealthequityitself.

HEIA scoping project References

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HEIA scoping project Appendix A

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AppendixA:HEIAStakeholderMapping

HEIAPilotProjectStakeholderMap

Pleaseaddto/commenton.

Stakeholder/KeyinformantCategory

Stakeholders/KeyInformants Contacts(withdetailsifavailable)

Stakeholderrole(interview,workshop,futurework)

Comments

Equity/inequality e.g.leadersinthefieldofinequalitiesandhealth

HIA e.g.HIApractitionerswithexperienceinincorporatingequityintoHIA

EquityFocusedHIA

CommissiononSocialDeterminantsofHealth(CSDH)

DepartmentofHealth/NationalHealthService

Globalpublicpolicy

PotentialHEIAusers,commissioners,funders

NGOs

HEIA scoping project Appendix B

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AppendixB:HEIAScopingreview–literaturesearches

HEIAscopingreview–inclusion/exclusioncriteria

Inclusioncriteria Exclusioncriteria

Methodologiesandtools

HIA,HIIA,HEIA,EFHIA,equitygauge,HEAT,equityaudit,otherIAswithanequityfocus

EqualityImpactAssessment,non‐IAmethodologies,methodsortools–unlessspecificallyincluded

Methods Clearandfulldescriptionofmethodsused

Incompleteoruncleardescriptionofmethodsused

Equity Separateassessmentofequityimpacts,includingtermssuchasinequity,inequality,disparity,variation,differential,vulnerablegroups.

No,limitedorunclearassessmentofequityimpacts.Equityimpactslimitedtoadiscussionofthedifferentialimpactonindigenouspopulations.

Focus Policy,strategyandprogrammeassessments

Projectassessments

Determinantsofhealth

Inclusiveofsocialdeterminantsofhealth

Limitedtobiomedicalorhealthcarerelateddeterminants

Operation Local,national,global Noexclusions

Datasources Electronicdatabases:WoK,CSAabstracts4;GoogleandGoogleScholar;GreyliteratureDB:OpenSigle;HIAwebsites5;RequestsforInformationsenttoHIAwebsitesandlistservs;personalrecommendations.

Allothers

Publicationdates

1990+ 1989‐

Publicationtypes

Methods,implementation,evaluation,reviewsofprimaryresearch

Editorials,commentary,opinionpieces,letters,reviewsnotofprimaryresearch

Language English NotEnglish

Country All Noexclusions

Abstract Mustincludeanabstractorsummary Noabstractorsummary

4ASSIA;BHI;BiologicalSciences;EconLit;EIS;EnvironmentalSciencesandPollutionManagement;MEDLINE;CSASocialServicesAbstracts;CSASociologicalAbstracts;CSAWorldwidePoliticalScienceAbstracts

5HIACommunityWiki,HIAConnect,HIAGateway,HIANetwork,HumanRightsImpactResourceCentre,IAIA,IMPACT,LondonHealthCommission,ScottishHIANetwork,WelshHIASupportUnit,WHOHIApage

HEIA scoping project Appendix C

HEIA/IntSch/003 66

AppendixC:HEIAInterviewSchedule

Introduction

1. Asareminder:ThepurposeofthisprojectistodefineandtestthekeyconceptsunderpinningHealth Equity Impact Assessment (HEIA) and to determine the scope for a new HEIAmethodology. The project aims to understand how health equity impacts could best beassessed,thewaythatequity iscurrentlyaddressed in impactassessments,andhowequityassessmentcouldbebetterincludedinHealthImpactAssessment(HIA).

2. Interviewerintroducesthemselves.

3. Interviewertoremindtheparticipantthattheinterviewwillberecorded.

4. Intervieweraskstheparticipantto introducethemselvesandtodescribetheirexperience inrelationtohealthequity/HIA.

Allinformants

5. Whatdoeshealthequitymeantoyou?

6. Whatfactorsalterhealthequity–positiveandnegative?

• Forexample:increasedincomeinequalityhasanegativeimpact• Doyouhaveanyexamples?

7. Whatactionswouldincreasehealthequity?

• Forexample:policytoredistributeincome• Doyouhaveanyexamples?

8. Whatdifferentimpactsandmethodologicalconsiderationsaretherewhenassessingthehealthequityimpactofglobalpolicies,suchasinternationaltradeagreementsormacroeconomicpolicies,thanwhenassessingthehealthequityimpactoflocalandnationalpolicies,suchaseducationoremployment?

• Examplesofdifferentimpacts:globalvsnational/local• Examplesofdifferentmethodologicalconsiderations:gobalvsnational/local

9. Howcouldweassessthisdifferentlytowhatisalreadybeingdone?

• Forexample:isthereaneedtoadaptHIA?• Doyouhaveexamples?

10. Whatspecificfactorswouldneedtobeconsideredtoprospectivelyassesstheimpactofpolicyonhealthequity?

• Globally?• Regionally?• Nationally?• Locally?

HEIA scoping project Appendix C

HEIA/IntSch/003 67

11. Whatarethebarriersandfacilitatorsforpolicychangetomaximisehealthequity?

• Forexample:presenceorabsenceofpoliticalwilltoaddressmacroeconomicinequalities.

Impactassessmentpractitioners

12. Whatarethestrengthsandweaknessesofcurrentimpactassessmentmethodologiesinassessinghealthequity(e.g.HealthImpactAssessment(HIA),HealthInequalitiesImpactAssessment,EquityFocusedHIA)?

• Strengths–examples• Weaknesses‐examples

13. Towhatextentdoexistingtoolsenabletheeffectiveassessmentoftheimpactofpolicyonhealthequity?(E.g.HealthEquityGauge,EqualityImpactAssessments)

• Strengths–examples• Weaknesses‐examples

14. Whatarethebarriersandlimitationstoassessinghealthequityimpacts?

• Forexample:accesstorelevantdata;thequalityofdataavailable;evidenceoftheimpactofspecificpoliciesandinterventions.

15. WhatarethebarriersandfacilitatorsforimplementingrecommendationsaimedatincreasinghealthequityfromHIAorotherhealthequitytoolsandmethodologies?

• Forexample:Commitmenttoimplementingtherecommendations,evenwhentheyarepoliticallydifficult.

16. Whatwouldneedtobedonetoincreasetheuptakeofrecommendationsaimedatincreasinghealthequity?

• Canyougivesomeexamples?

17. Takingallthisintoaccount,wouldanHEIAmethodologydifferfromHIA?

• Ifso,inwhatways?• Ifnot,whatneedstobedonetomakeHIAmoreequityfocussed?

18. AreyouawareofanyworkcurrentlybeingdonetodevelopanHEIAtool?

HEIA scoping project Appendix D

68

AppendixD:HEIAWorkshopProgramme

HealthEquityImpactAssessmentPilotProject

Twodayinternationalworkshop,5thand6thOctober2009

TheForesightCentre,Liverpool,UK

WorkshopProgramme

Day1:Monday,5thOctober2009

10:30–11:00 Registration;teaandcoffee

11:00–11:30 Welcomeandintroductions

Chair:AlexScott‐Samuel

11:30–11:50 BackgroundandpolicycontextforHEIA

AlexScott‐Samuel

11:50–12:20 Videoclipsfrom“UnnaturalCauses:Isinequalitymakingyousick”

12:20–13:00 ProjectintroductionandfindingsfromphasesIandII

SuePovall

13:00–13:45 Lunch

13:45–14:00 Definitionsofkeyconcepts;IntroductiontoHIA;Introductiontogroupwork

SuePovallandDebbieAbrahams

14:00–15:30 Groupwork1:

StrengtheningequityinHealthImpactAssessment–thelocalcontext

15:30–15:45 Groupfeedbackanddiscussion

Chair:DebbieAbrahams

15:45–16:00 Break

16:00–17:30 Groupwork2:

StrengtheningequityinHealthImpactAssessment–theglobalcontext



19:30 WorkshopDinner:

EgoMediterraneanRestaurant

HopeStreet,Liverpool

Phone:01517060707

HEIA scoping project Appendix D

69

Day2:Tuesday,6thOctober2009

09:00–09:15 Opendiscussiononemergingthemes


09:15–09:30 IntroductiontoGroupWork3andGroupWork4

AlexScott‐Samuel

09:30–11:00 Groupwork3:

EquityrecommendationswithinHIA/HEIA



11:15–11:30 Break

11:30–13:00 GroupWork4

MakingHEIAhappenandmaximisingitsimpact



13:15–14:00 Lunch

14:00–16:00 HealthEquityImpactAssessment:towardsaconsensus

Chair:AlexScott‐Samuel

16:00 Close

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