Equity Focused Health Impact Assessment – A Step Forward or Two Steps Backwards more

FOR SUSTAINABLE AND PROSPEROUS SOCIETY HEALTH ECONOMICS Equity Focused Health Impact Assessment – A Step Forward or Two Steps Backwards (Opinion) Jordan Panayotov Equity Focussed Health Impact Assessment – A Step Forward or Two Steps Backwards Opinion Jordan Panayotov Health inequalities (HI) are topic for intensive discussions since 1990 when Whitehead defines them as differences in health among individuals, which are considered to be avoidable and unfair. Panayotov (2006) points out that from economics point of view HI represent also inefficient and unsustainable allocation of limited public resources, therefore, he asserts that HI should be reduced not only on compassion ground. Health impact assessment (HIA) by definition is concerned with the “potential effects on the health of a population, and the distribution of those effects within the population”, Lehto and Ritsatakis (1999), and aims to maximize the health of whole populations, Quigley et al. (2006). Panayotov (2008a) explains the generative mechanisms which create, widen or diminish HI, and points out the role of HIA for reducing HI as a premise for sustainable wellbeing, Panayotov (2008b). Therefore, based on all of the above, Panayotov (2010) asserts that, HI should be one of the main domains of HIA, and any HIA which is not explicitly addressing HI is, in fact, inferior. However, Kemm (2006) notes that many HIAs, while describing differences between groups of the population, often “fall short of a proper analysis of distribution of impacts detailing how the various impacts would fall on different groups within the population”. Probably because of this, the UN Commission on the Social Determinants of Health (2008) has recommended assessment of health equity effects of public policy decisions by conducting health equity impact assessment (Recommendation: 10.3; 12.1; 16.7). There is no need to invent new name in order to fix the shortfalls in HIAs regarding addressing HI. A proper HIA should be able to identify the impacts of a policy, program, project or other intervention on the health of different groups within the population, i.e. the distribution of these impacts among the population; should analyse the trade-offs associated with different policy options, i.e. the differences in the distribution of the impacts among the population from different alternatives; and should make clear recommendations to reduce HI in order to maximize the health of whole population, i.e. should aim such distribution of impacts among the population which leads to narrowing the population bell while improving the mean, Panayotov (2009). Therefore, “health equity impact assessment” or “equity focused health impact assessment” is simply a tautology – stating that HIA should do what it actually must do by definition, if properly conducted. Apart from this, the use of new terms in order to draw attention to the importance of reducing HI, although done with good intentions (we assume), actually does more harm than good in several directions (fact). First, putting new names diminishes the value and credibility of HIA. At 9th International HIA Conference in Liverpool, UK, October 2008, there was an intensive discussion about different (names of) HIAs. A person from the audience said: “Do not confuse the confused!” and he repeated it again, adding: “For me it’s difficult to sell HIA even now, and you are constantly changing it.” As illustration for the opposite – the use of one name – health technology assessment (HTA), although dealing with infinite variations of specific cases, always is named HTA and has widely recognised high value and credibility. Furu (2010) points out that “there should only be one assessment for health – namely Health Impact Assessment. The details of the Terms of Reference for the HIA will determine the scope and comprehensiveness of the assessment”. 1 Second, and more important, the use of “health equity impact assessment” or “equity focused health impact assessment” implies, whether the users of this term realize it or not, that there can be other types of HIA which do not specifically consider equity and this can be perfectly OK, i.e. such HIAs are also good, thereby equalizing poor and inferior HIA (not explicitly addressing HI) with the proper ones (explicitly addressing HI). Not only this diminishes the value and credibility of HIA, but more importantly this undermines the whole idea for addressing and reducing HI, since these can be simply ignored in the other HIAs. What HIAs need in order to be “equity focused” is a theoretical framework that allows proper analysis of the distribution of the benefit among the population from different policy options. Panayotov (2008a) points out that different combinations between the winners and the losers at local level in time will determine the distribution of impacts on health within the population, no matter whether the primary objective is improving health of whole populations, or the primary objective is different than health (i.e. in other sectors: transport, education, agriculture, etc.), however with impact on health of populations. Actually such theoretical framework exists – Panayotov Matrix, and it is only a matter of time to be applied in practice. The sooner – the better for conducting proper HIAs and reducing health inequalities around the world. Melbourne, 11.01.11 References: Commission on Social Determinants of Health, 2008, “Closing the gap in a generation: health equity through action on the social determinants of health”, WHO, Geneva, available at www.who.int/social_determinants/final_report/en (last accessed 11.01.2011) Furu P., 2010, Comments at Discussion about different names of HIA in “Health Impact Assessment Group” in Linkedin, available at http://tinyurl.com/HI4HIAdiscuss Kemm J., 2006, “Health impact assessment and Health in All Policies”, Ch.10 in “Health in All Policies – Prospects and Potentials”, Ministry of Social Affairs and Health, Finland, ISBN 952-00-1964-2 Lehto J. and Ritsatakis A., 1999, “Health impact assessment as a tool for intersectoral health policy”, Discussion paper for a conference on HIA: From Theory to Practice, Gothenburg 28-31 October 1999, WHO Europe Centre for Health Policy, WHO Regional Office for Europe, Brussels Panayotov J., 2006, “Equity – A Premise for Efficiency in Public Health”, presentation at 11th World Congress on Public Health, Rio de Janeiro, Brazil, August 2006, available at http://icare.academia.edu/JordanPanayotov/Talks (last accessed 11.01.2011) Panayotov J., 2008a, “Public Health and Average Health Status: Do Health Inequalities Matter?, ICARE, 08 August 2008, available at http://icare.academia.edu/JordanPanayotov/Papers (last accessed 11.01.2011) Panayotov J., 2008b, “Health Impact Assessment: Is Sustainable Wellbeing Possible Without Health Equity?”, presentation at 9th International HIA Conference, Liverpool, UK, October 2008, available at http://icare.academia.edu/JordanPanayotov/Talks (last accessed 11.01.2011) Panayotov J., 2009, Evidence in Public Health and Health Impact Assessment, ICARE, 1 February 2009, available at: http://icare.academia.edu/JordanPanayotov/Papers (last accessed 11.01.2011) Panayotov J., 2010, “What should we strive for in urban development – increasing Average Health Status or decreasing Health Inequalities: the role of HIA”, presentation at WHO HIA Conference, 7 April 2010, Geneva, Switzerland, available at http://icare.academia.edu/JordanPanayotov/Talks (last accessed 11.01.2011) Quigley R. et al., 2006, “Health Impact Assessment International Best Practice Principles”, Special Publication Series No. 5. Fargo, USA: International Association for Impact Assessment. Whitehead M., 1990. “The concepts and principles of equity and health”, World Health Organisation, Regional Office for Europe, Copenhagen 2