GETTING HEALTH IMPACT ASSESSMENT INTO THE POLICY PROCESS IN HUNGARY

Conditions for Developing Healthy Public Policy

Margit OHR
International Policy Fellow
 

Summary

Introduction
This policy paper is one outcome of my work within the International Policy Fellowship Programme of the Open Society Institute, Budapest, Hungary during the 2002/2003 fellowship year.

The paper makes some important policy recommendations relating to the implementation of HIA into Government policymaking in the context of EU Accession. These recommendations are based on my research paper and a workshop held with key Hungarian stakeholders (24 March 2003) to consider the policy implications of my research findings. This Policy Paper will be translated into Hungarian and will be sent to the workshop participants and others for comments before submitting it to the leadership of the Ministry of Health, Social and Family Affairs. The implementation of the recommendations will depend on the decisions of policy makers at the Ministry and elsewhere.

Aims and objectives
The aim of the policy paper is consider those factors identified in the research as being supportive or barriers to the use of HIA in order to prepare the ground for capacity building for HIA.

Key findings of the Research Paper and the workshop in Hungary
In Hungary:

• there is understanding of the complex policy challenges facing Government. However, policy design and critically, implementation is still pursued through sectors and sectoral interest groups rather than developing more flexible, intersectoral means of identifying, designing and delivering action. In part this reflects a lack of investment in modernising public administration, especially in the health sector
• relatedly, an evidence-based working culture is not widespread in policy and professional arenas
• there is recognition that capacity building is needed to develop the necessary infrastructure in order to conduct HIA
• finally, policy and strategy is still largely developed by small closed groups of expert and bureaucratic interests lacking transparency and meaningful engagement with wider stakeholder interests.

The assumption informing this research was that EU Accession would stimulate some of the changes necessary to modernise policy making/public administration and enable the adoption and development of relevant methods such as HIA. So close to EU Accession, this research shows that in Hungary commitment to and investment in dealing with policy and public administration development e.g. as a platform for applying HIA methodology, is not obvious. Effective capacity building will need educational, institutional and strategic level investment, not least to tackle all the political and more seriously, the institutional-cultural barriers to development.

General Recommendations
The main recommendations are given below:
 

• Developing capacity and confidence in HIA should be part of a broader effort to modernise policy making and institutions in Hungary.
• Carrying out HIA should be an essential part of government planning and decision making in order to place health in the centre of the decision making process.
• Under the Hungarian system, the requirement for HIA should be regulated by law with clear lines of accountability through the Minister for Health, Social and Family Affairs ultimately reporting to Parliament.
• Developing capacity (strategic, institutional and educational) for HIA should be championed by the ‘modernising’ centre of gravity in the Hungarian Public Administration.
• Responsibility for guiding implementation of HIA across Government should be located in a background institution working mainly in relation to the Ministry of Health, Social and Family Affairs, Ministry of Finance and the Prime Minister’s Office.

Hungary is expected to join the EU in May 2004. In this context the ultimate goal of this work is to contribute to first steps to build capacity within the Hungarian system to conduct health impact assessment of any relevant policy or programme at national level .
 

Despite the adoption of several public health strategies since 1989, health inequalities in Hungary have got wider during the transition to a market economy. The country currently has one of the lowest levels of life expectancy and poorest premature mortality rates for males in the CEE region. At the same time Hungary has been experiencing steady economic growth and is an EU accession country. This raises a basic question about how, from a public health perspective, this economic and political transition can be managed in order to minimise its negative health impacts especially on the most vulnerable groups in society.

There is some recognition in Parliament and at the most senior level in the Public Health & Medical Officers Service in Hungary, that solutions to improving population health are likely to be found outside the health care system.
 

In December 1999, as part of a round of international events designed to share experience and innovation on HIA, Hungary hosted a meeting on HIA. At that time there appeared to be little interest in the Ministry of Health in the value of HIA and scepticism about its relevance in the context of Hungarian policy making. By contrast, the Environment Ministry was developing capacity in the commissioning and use of environmental impact assessment.

More recently, in May 2002, the Socialist/Free Democrat coalition Government took office following a general election. Public announcements by senior Government figures seemed to commit the Government to designing and delivering health-driven policy in all sectors of public administration. This mirrors the range of competency in health matters set out in the Treaty of Amsterdam of the European Union. Not without coincidence, Hungary is on track for accession to the EU in May 2004.

This new approach to healthy public policy will, for this Government, be underpinned by intersectoral action on health and continuing reform of public administration in Hungary. Together, they appear to provide a supportive environment for the introduction and implementation of HIA.

More concretely:
 

• a new Public Health Division was established at the Ministry of Health, Social and Family Affairs in September 2002 with interest in championing health development
• provision for a regional health development function alongside Regional Development Committees was included in the National Development Plan for Hungary submitted to the EU
• the Hungarian Parliament had a debate of the new National Public Health Programme in February/March 2003
• subsequently, further strategic and institutional development in the areas of health development and Public Health are planned during 2003-2005.

One of the options under consideration is that HIA can be institutionalised in the governmental sector through a new background Health Policy Institute that could be established in relation to the MoHSFA.
 

The attention paid in this paper to HIA does not minimise appreciation that Government and public administration in Hungary is confronted by many significant challenges, especially related to EU Accession. In that sense, attention to HIA might seem a luxury. However, the attention given to HIA is important because it helps to illustrate how these broader challenges are/are not being met.

According to the findings of my research and the stakeholder workshop the following areas should be addressed in developing action at political, institutional and professional levels.
 

• Hungary needs to deal with several political/policy barriers to developing the use of HIA at national governmental level. At the same time Hungary can use the support from the international community and from its own development opportunities as well.
• The Minister for Health, Social and Family Affairs should have responsibility for reporting to Parliament, at least annually, on Health Impact Screening activity and HIAs conducted and-or commissioned and what subsequent action was taken by relevant Ministries and organisations. This would also ensure that other Ministries have to account for corrective actions taken or not taken in response to HIAs.
• Hungary needs to address problems located in institutional cultures, structures and relationships, developing a new attitude and practice for organisational culture that is supportive of evidence-based decision making, intersectoral and team working and involving target population groups in planning and decision-making.
• Key stakeholders, especially public health professionals and researchers need to develop and promote the necessary evidence base to support the use of HIA.
• In terms of resources Hungary needs to identify and exploit the opportunities that are available and with realistic budgets, start to develop capacity to carry out HIA.

Relatedly, experience from elsewhere shows important directions for the development of HIA in Hungary. For example,
 

• Carrying out HIA should be an essential part of government planning and decision making in order to place health in the centre of the decision making process.
• When facing potential health risk detailed impact assessment is needed in the interest of eliminating the risk or achieving a better health gain.
• Carrying out HIA is reasonable and practical, with findings from a HIA it is really possible to make changes in the decision making process.
• The HIA should be jointly owned by the health sector and other sectors. Determining that a HIA is necessary and initiating it should be a cooperative decision between the relevant ministries. Negotiating and implementing the recommended modifications is the responsibility of the relevant decision makers and Government offices.
• HIA can be an integrated part of other impact assessments but also can be carried out independently. The selection of the necessary methods and tools depends on the specific task (Adapted from SNAP, 2000).

The main recommendations are given below.

If it is possible, existing capacities should be used and built on it. It is important to ‘map’ recent impact assessments in the country taking into considerations their legal regulation. These can be used as models for forming the regulation for the implementation of HIA.

In part of mapping recent impact assessment and its regulations connection needs to be made with stakeholders from the:
- Ministry of Environment
- Prime Minister’s Office
- Ministry of Finance
- Ministry of Health, Social and Family Affairs
- Others if necessary.

The Parliament should adopt a resolution as first step which is essential and necessary for the legitimacy of HIA. For example there is no document like this in the UK. Only the Environmental Impact Assessments are regulated by the law. This was created within the frame of EU regulation. This is why it would be important for Hungary to take part in a potential EC pilot project. This could help the formation of this resolution which would regulate the HIA at the formulation of those policies which might influence the health status of the people.

The capacity building process should have: strategic, institutional and educational component as well.

4.2.1 Strategic development

The Hungarian Government should develop mechanisms to consider health in national policy making, and to support this at all levels. The assessment of the health impacts of policies at national level should be a priority since the achieved effects are more fundamental and resource efficient than confining assessment at local or program level.

The Ministry of Health, Social and Family Affairs together with other sectors (e.g. Ministry of Environment, Finance, Prime Minister’s Office) should support the implementation and use of HIA in Hungary as the integral part of strategic decision making both at national and at local government offices and other organizations.

After the necessary preparations a National Advisory Group should be formed under the Ministry of Health, Social and Family Affairs, which would be responsible for supervising a Unit dealing with supporting the implementation and use of HIA in Hungary.

Tasks of this National Advisory Group:
- finding the role and place of HIA in the decision making process in Hungary
- identification of people responsible to conduct HIA
- supervision of procedures and methodologies in HIA in Hungary
- supporting the institutionalisation of HIA
- guiding the legitimisation process

A paradigm shift has to take place at  political, professional and society levels on the issue of how to think about health and the responsibilities for health. Several dimensions of this shift have to be communicated at the relevant levels of the society. The platform of this communication can be a national conference: National Intersectoral Conference on Health Impact Assessment for decision makers, professionals and the general public in Hungary.

4.2. 2 Institutional development and market assessment

An independent Research and Development or Health and Public Policy Unit should be formed, which is responsible for developing a plan for implementation and support of technical protocols of HIA in Hungary. There are several alternatives for positioning such a Unit.

First, the Unit could work within the frame of a civil organization in order to have opportunities to get resources from several sources; not only from the Government. This civil organisation could use accessible and existing experiences and results of both national and international research projects (e.g. M. Ohr, OSI/IFP research, capacities of the CEU, Ministry of Environment, others).

Second, funding could be provided for a Unit working within a background institute of the Ministry of Health, Social and Family Affairs. This Unit would advise on those policies which have to be examined concerning their potential impact on health, supports screening within the relevant Ministry and where necessary conduct or commission full HIAs. The results would then be shared with the Ministry that is responsible for acting upon the recommendations.

Third, other alternatives are (i) this Unit could be established as a background Institute to the Ministry of Finance, recognising that Ministry’s role in determining the shape of the Government’ policy programme (ii) placing the Unit within the Prime Minister’s Office, as part of a broader drive to modernise Government and public administration.

Important first steps would include a market assessment of organisations who might be able to conduct Health Impact Assessment and co-ordinating a Pilot Project. The latter could be resourced through the current MATRA-funded health promotion project in Hungary. A skills audit undertaken as part of this project identified HIA as a key development issue (see also 4.2.3 below).

4.2.3 Educational development

Together with the MATRA funded work one option can be training on Health Impact Assessment (calling in Dutch and possibly English experts) with relevant people from the Ministry of Health, Social and Family Affairs, Prime Ministers Office, Ministry of Finance and Environment and other stakeholders from the workshop participants.

In discussion with one of the MATRA project experts it is suggested that developing awareness and orientating Hungarian stakeholders to HIA could be achieved through setting up a Hungarian/Dutch Working Group in which the Hungarian participants ‘learn by doing’ with guidance from Dutch colleagues rather than through a traditional (but passive) training course approach.
 

Abbreviations
DSoPH        Debrecen School of Public Health
MoHSFA    Ministry of Health, Social and Family Affairs
MoE     Ministry of Environment
NAG     National Advisory Group
PMO     Prime Ministers Office
UoN     University of Nottingham
WGED     Working Group for Educational Development
WGID     Working Group for Institutional Development
WGLF     Working Group for Legal Framework
WGSD     Working Group for Strategy Development

The necessary budgetary proposal needs to be identified for any future work, together with the necessary time scale. It is not possible to attach these documents together with this Policy Paper, because there is much uncertainty in the decision making process and about institutional development at this stage.

It is recognised that these recommendations might need to be modified as a consequence of learning during their implementation.

Proposal for the composition of the different working groups for each category of recommendations.

Name	Function in the working group	Organisation
?	Charman of the WGLF	?
Margit OHR	Focal Point	OEFK
Tamás KOÓS	Representative of the MoHSFA	Head of the Public Health Division
Edina DANCSÓKNÉ FÓRIS	Representative of the MoE	Department of Strategy Planning and Co-operation
Gábor KAPÓCS	Representative of the PMO	Department for Social relationship
István ERDÉLYI	Legal expert	MEDICONSULT

The working group for Legal Framework will be responsible for the overall guidance and development of the legitimisation of HIA into the decision making process and to evaluate this progress against the pre-determined parameters. The WGLF will meet at least two times a year, having its first meeting after finalisation of the Policy Paper.

5.2.1 Composition of the Working Group on Strategy Development (WGSD) = National Advisory Group (NAG)
 

Name	Function in the working group	Organisation
Peter MAKARA	Charman of the WGSD = NAG	Adviser to the Administrative State Secretary of the MoHSFA
Margit OHR	Focal Point	OEFK
Tamás KOÓS	Representative of the MoHSFA	Head of the Public Health Division
András JÁVOR	Representative of the National Public Health Programme	?
Jonathan WATSON/MATRA	International expert/MATRA	UoN/MATRA
Róza ÁDÁNY	Director of the DSoPH	Director of the DSoPH
Attila KOVÁCS	Representative of ÁNTSZ	Deputy Director of the Chief Medical Office

The responsibility of this working group is describe in the 4.2.1 section. The NAG will meet at least two times a year, having its first meeting after finalisation of the Policy Paper. The composition of the working groups for institutional and educational development (WGID, WGED) will be set up by the NAG as well.
 

Scottish Needs Assessment Programme, (SNAP, 2000) Health Impact Assessment: Piloting the Process in Scotland, Office for Public Health in Scotland: Glasgow.
 

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