Developing capacity in cross-sectoral governance: opportunities and barriers to the use of health impact assessment in Hungary.

Fellowship issue area: EU Accession and Health

Margit Ohr
National Institute for Health Promotion, Hungary, Budapest

1. Introduction
EU competence in health is not limited to public health action as defined in the current EU Health Strategy. Under the terms of the Amsterdam Treaty, there is a specific requirement that a high level of human health protection be ensured in the definition and implementation of all Community policies and actions. Among other things, this means that activity related to the Internal market, social affairs, research & development, agriculture, trade, development policy and the environment, must be appraised for its potential impact on the health and well being of EU citizens.

Looking at current practice in Hungary in the context of preparation for EU accession, this research proposal asks:
 

• Do policy makers currently consider the health impacts of non-health sector policy?
• What capacity exists within Hungary to use health impact assessment methodology as a systematic means of appraising the potential and actual impact of policy?
• What action could be taken to improve understanding, confidence and expertise in health impact assessment?

2. Background
Despite the adoption of at least four 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 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 outwith the health care system.

2.1 Reasons for considering the wider health impacts of government policy

(a) The contribution of health care to population health
There is now overwhelming contemporary evidence that the social environment (incomes, work, social networks) is a major influence determining why some people are healthy and others are not [Lavis and Sullivan, 1999; Marmot and Wilkinson, 1999; Gillies, 1998; Blane, Brunner and Wilkinson, 1996; Wilkinson, 1996; Evans, Barer and Marmor, 1994]. In a sense, population health is an emergent capacity arising from the integrated effects of health-related social, economic and cultural activity. It is not an outcome that can really be bought from health sector-directed expenditure. After reviewing the evidence the World Bank concluded that there is no relationship between population health and health care system spending (World Bank 1993).

• In 1996, the US Surgeon General interpreted the evidence to say that 70% of the general causes of premature death and disability are due to the interaction of environment and lifestyle (of the other 30%, 10% = poor access to medical care and 20% = genetic) (May 1996).

What this means is that the health sector has significantly less responsibility for overall changes in mortality, morbidity and life expectancy than was previously thought.  The implication of this for public health is that it needs to influence and contribute to activity outside the health sector where these have the best potential for eventually delivering significant health improvements.

(b) Public health, policy and government
The OECD says “Governments are challenged to critically examine the rigidities in their policy-making systems, and to seek ways to make them more flexible” (OECD 2000).

Since most citizens aspire to a better quality of life, policy makers have to ask ‘what action (public and private) needs to be taken to maintain and enhance quality of life, including health, at all levels of society’? This is not a question primarily about how to deliver better health care or even better programmes of disease prevention. The policy challenges and opportunities to building successful, cohesive, dynamic and healthy societies do not lie with any one sector of Government or of society. We need to take a systems approach (Evans & Stoddart, 1990) and this leads to the conclusion that ‘it all matters’. So, a primary challenge for public health is how to influence and shape the wider policy process while not getting trapped in a narrow association with traditional health policy outputs. One method that is increasingly taken seriously in Western Europe and the Nordic countries for its ability to provide added value to the policy-making process, is health impact assessment (HIA). However, despite a conference on the subject run by the WHO European Centre for Health Policy in 1999, policy-makers in Hungary do not appear to have seriously contemplated the systematic use of HIA in appraising the Government’s policy programme.

2.2 Health Impact Assessment
In many countries there is recognition that the spectrum of social, economic and human development policies are so closely interrelated that proposed decisions in one sector may impact on the objectives of other sectors. In recognition of this, specific legal and administrative rules, procedures and methods have been developed in many countries to assess the impacts of policies for example on the environment, employment, economic growth or competition, on cultural and social factors, or on ethnic groups and gender. The general objective of such assessments is to improve knowledge about the potential impact of a policy or programme, inform decision-makers and affected people, and facilitate adjustment of the proposed policy in order to mitigate the negative and maximize the positive impacts.

Although policies in other sectors can have a considerable influence on health and the production or prevention of illness, disability or death, this has so far only been considered to a limited degree, mainly in relation to environmental and social impact assessments. Recent attempts to take a more integrated approach to health and development has put HIA high on the agenda of some governments in Europe (at national, regional and local levels), and of international organizations including WHO and the World Bank. A similarly increased interest is reflected in research circles.

These developments gave a strong impetus to the need for developing common understanding about the core elements of health impact assessment and an international exchange of experience and innovations. A milestone in this process was the publication of the Gothenburg Consensus Paper on Health Impact Assessment in December 1999. According to this Consensus Paper, HIA includes the following stages:
 

• Screening the potential policy or programme for linkages with health. If the available information is limited then the scope of further action has to be agreed
• Scoping of HIA which helps identify: which potential (in)direct health impacts of the policy/programme need to be better explored; for which specific population groups; using which methods; resources; who participates and over what time frame
• Appraisal of the HIA report which may lead to requests to add information and reappraisal
• Action - adjusting the proposed decision or intention, thus acting on the results of the HIA
• Monitoring and evaluation of expected impacts.

3. Research questions
The following research questions will be explored during the period of the fellowship:
 

• What might be considered current good practice in health impact assessment?
• Do policy makers in Hungary currently consider the health impacts of non-health sector policy?
• Is the requirement for HIA considered as a consequence of EU accession?
• What capacity and capability exists within Hungary to use health impact assessment methodology as a systematic means of appraising the potential and actual impact of policy?
• What action could be taken to improve understanding, confidence and expertise in health impact assessment?

The proposed study will be facilitated by:
 

• use of the applicant’s existing professional networks and contacts (UK, Sweden, WHO/EURO, Norway, MoH Hungary)
• the applicant’s participation in an international working group asked to scope ideas for the strategic development of public health in Hungary as a driver for cross-sectoral action (Watson et al 2001).

Blane D., Brunner EJ. and Wilkinson R. (1996) The evolution of public health policy: an anglocentric view of the last fifty years. In Blane D., Brunner EJ. and Wilkinson R. (eds.) Health and Social Organisation: towards a health policy for the 21st century. London: Routledge.

European Commission (2000) European Union Health Strategy (2001-2006). COM (2000) 285 Final. Brussels: European Commission.

Evans R., Stoddart G. (1990) Producing health, consuming health care. Social Science & Medicine  31(12): 1347-63.

Gillies P. (1998) Social capital and its contribution to public health. In: E. Ziglio, D. Harrison (eds) Social Determinants of Health: Implications for the Health Professions. Genoa: Italian National Academy of Medicine, pages 46-50.

Lavis J and Sullivan T (1999) Governing Health. In Drache D. and Sullivan S. (eds.) Health Reform: Public Success and Private Failure. London: Routledge.

London Health Commission/Environment Committee of the Greater London Assembly. (2000). Health Impact Assessment of the Draft Air Quality Strategy. London: London Health Commission.

Marmot M. and Wilkinson RG. (eds.) (1999) Social Determinants of Health, Oxford: Oxford University Press.

May A. (1996) (Quoting Jo Ivey Boufford, Principal Assistant Secretary of State for Health, US Department of Health and Human Services) Forward thinking. Health Service Journal, 4 July.

The World Bank (1993) World Development Report 1993. Oxford: Oxford University Press.

Watson J, Ohr M, Brown C, Wyes H (2001) The contribution of public health to national development in Central and Eastern Europe. Programme development proposal from Public Management Development Consortia to Chief Medical Officer (Hungary) [accepted May 2001]

Wilkinson R. (1996) Unhealthy Societies: The Affliction of Inequality. London: Routledge.

WHO European Centre for Health Policy (2000) Gothenburg Consensus Paper on Health Impact Assessment. Brussels: WHO/EURO.
 

Budapest, June 2001.
 

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