HEALTH AND EU ACCESSION:

SOME CHALLENGES TO THE USE OF HEALTH IMPACT ASSESSMENT IN HUNGARY

Margit OHR
International Policy Fellow

Contents

1. Factors affecting the use of HIA in Wales
2. HIA’s coordinated or produced by NSPH
3. Factors affecting the use of HIA in Hungary

Figures

1. Key stages in HIA
2. Perceived barriers to using HIA in government policymaking in European countries
3. Comments on HIA made by Tessa Jowell MP [former] Minister of State for Public Health
4. main objectives of the Dutch plan of action to develop HIA in 1995
 
 

Acknowledgements

I would like to thank the Open Society Institute International Policy Fellowship Program for awarding me a Fellowship that enabled me to carry out this policy research study. In particular, Pamela Kilpadi (IPF Program Manager, Mladen Momcilivic (IPF Program Coordinator) and Csilla Kaposvari (Public Health Fellows Coordinator) gave me support and encouragement during my fellowship year (2002/2003).

I would like to express gratitude to my mentors (Hungarian mentor: Dr. Mihály Kökény, Parliamentary Secretary of State, Ministry of Health, Social and Family Affairs; International mentor: Dr. Martin Birley, Director, International Health IMPACT Assessment Consortium, University of Liverpool). Both gave me their time and helped to inform the development of my research and access to networking and training opportunities. In addition, Dr Birley facilitated my involvement as a third party in a current EU-funded (SANCO) project: Policy Health Impact Assessment for the European Union.

I am grateful to all of the people I interviewed for their willing participation and interest in the research.

Mention must also go to Ceri Breeze of the Public Health Strategy Division, Welsh Assembly Government, for involving me to the Pan-European HIA Survey 2002 and to his colleagues Heather Giles and Marc Boggett for they support of these work.

Finally I would like to thank to Edit Sebestyén (health promotion expert) for her research assistant work that helped me to carry out this work.

If readers have comments or feedback on this paper, please contact me at ohr@policy.hu
 
 

Summary of findings and recommendations

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

The paper discusses opportunities and barriers to the use of Health Impact Assessment in Hungary and makes some key policy recommendations relating to the implementation of HIA in the context of EU Accession.

The paper starts by providing some relevant background on the use of HIA in the European Union and then presents more detailed case studies based on experience of using HIA in the UK and The Netherlands. It then goes on to identify and assess the current situation in Hungary with particular attention to opportunities and barriers to understanding and using HIA.

Aims and objectives of study
This study is the first step to look at and analyse all the significant factors that can be supportive and barriers to the implementation of HIA into the national decision making process. The aim of the study is to identify these factors and by dealing with them prepare the ground for capacity building for HIA.

Key findings
The key findings of this study relate to the following categories: evidence, political/policy, institutional and resources. Examination of the use of HIA in the EU and especially for this study, in the UK and Netherlands, show that there remain significant barriers to the use of HIA. However, the policy context is broadly supportive of efforts to use HIA in both the UK and Netherlands. For example, key policy drivers are: evidence-based action, intersectoral responses and community participation in policy and planning, to complex policy challenges (poverty, sustainable development, health inequalities). By contrast, in Hungary:
 

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.

Recommendations
The main recommendations are given below.
 

Key words: modernisation, health impact assessment, policy, barriers, opportunities, comparison, capacity building, Gothenburg Consensus statement, England, Scotland, Wales, Hungary, good practice, Netherlands, European Union, World Health Organization
 
 

1. INTRODUCTION

EU competence in health is not limited to simply to activity labelled health or public health. Under the terms of the Amsterdam Treaty, there is a specific requirement that
 

This means that a broad range of activity (e.g. related to the Internal Market, structural funds, social affairs, social inclusion, agriculture, the environment, trade and development policy) must be appraised for its potential impact on the health and well being of EU citizens.

Hungary is expected to join the EU in May 2004. In this context the purpose of the work reported in this paper was to explore factors that might affect the use of Health Impact Assessment in Hungary. Two main sources of information inform this paper: (i) published experience from among EU member states and (ii) findings from indepth interviews with Hungarian stakeholders.

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 .

1.1 Policy research questions
The following research questions were identified at the start of the Fellowship and then explored during the year:

Review of HIA methods and practice:

The Hungarian data was collected by interviews with key Hungarian stakeholders and published and unpublished public health policy documents. I couldn’t use the survey methodology, like other European countries in the Pan-European survey, because Hungary was not in the position to answer for the questionnaire in details. But I could use the questionnaire as an interview guide for my in-depth interviews. The questionnaire was structured around several key themes:

• Broad policy context

• Awareness and understanding of health impact assessment

• Use of health impact assessment to date

• Other approaches and other forms of impact assessment

• Issues related to developing further the use of health impact assessment

I asked the respondents to feel free not the answer for those questions that are not relevant to them. All interviews were conducted in Hungarian and they were then fully transcribed. The resulting transcripts were read several times to better understand the information being provided by informants. After this, the transcripts were examined again to identify shared and different issues. These were then grouped under opportunities and barriers categories for further analysis. For more in-depth analysis I created new sub-categories: evidence, political/policy, institutional, resources and I did comparison with the Wales data as well.
 

2. HEALTH IMPACT ASSESSMENT IN THE EUROPEAN UNION

This section provides some background to the development of HIA in Europe and especially the legitimacy and requirement for HIA given by the European Union in its conduct and the conduct of member states and pre-Accession countries.

2.1 Development of HIA in Europe
The development of HIA in Canada, Europe and elsewhere was facilitated by the emergence and acceptance of now overwhelming contemporary (and historical) evidence that
 

What this means is that the health care sector has less impact on and responsibility for changes in mortality, morbidity and other health status indicators than perhaps the public and many politicians had thought.

Work by the WHO Centre for Health Policy (ECHP Policy Learning Curve Series 2001, Number 4; 2001, HIA Discussion papers Number 1) and others (e.g. OECD/PUMA 2000, Cabinet Office 2000) demonstrate that in many countries there is understanding that proposed policy decisions in one sector may impact on outcomes in other sectors. For example, this has lead in some countries to the development of tools and methods to assess the impact of economic and social development policy decisions on the environment. The purpose of such an assessment is to: improve knowledge about the potential or actual impact of a policy or programme; inform decision makers and any affected communities; and enable changes to be made to proposed policies/programmes in order to help manage negative impacts and promote positive impacts.

Building on experience and learning from environmental and social impact assessment work, there has been increasing interest in health impact assessment. Development of HIA has varied according to circumstances in different countries and the interests of early champions. For example, in the UK HIA was developed and applied at local level with little national coordination and application in contrast to its development in The Netherlands.

This fragmented pattern of development led to understanding of the need to develop a shared understanding about the core features of HIA through an international exchange of experience and innovation. An event in Sweden in December 1999 produced the Gothenburg Consensus Statement on Health Impact Assessment. According to this statement, HIA is defined as
 

The important common elements of HIA were also set out (see Figure 1).

Figure 1: Key stages in HIA
 

2.2 The EU Public Health programme
The new EU Public Health Programme (2003-2008) was implemented on January 1, 2003. It is a key instrument underpinning the development of the Community’s Health Strategy. The main objectives of the new EU Public Health Programme are:
 

The Programme will rely on work in four main areas: cross cutting themes, health information, health threats and health determinants. Health impact assessment is an example of action required within the cross cutting theme element.

2.3 HIA in the EU
Despite growing investment in and understanding of HIA methods and tools (see 2.1 above) relatively little was known until recently about the application of HIA within the EU. To inform the future development of health impact assessment within individual member states as part of the European Community’s Public Health Programme (see 2.2 above), a pan-European survey of health impact assessment at national government level has been undertaken. The survey, which covered EU Member States, accession States and European Economic Area countries, examined perspectives on, and use of, health impact assessment at national governmental level. The survey explored the barriers that exist or may be encountered. The following diagram summarises the results (Breeze C, 2003, in press)

Figure 2: Perceived barriers to using health impact assessment in government policymaking in European countries

 Source: Welsh Assembly Government, 2002

What Figure 2 shows are two main types of problem in getting HIA accepted and used as part of the policy process: (i) lack of understanding of the need for and benefits of using HIA (ii) lack of capacity (skills, expertise and resources and methods). These findings seem surprising given the weight of evidence outlined in 2.1 above. They suggest a need to improve the sharing of knowledge and expertise between academic/professional experts and policy makers and the need to invest in HIA as a normal part of the policy making process. Recognition of the need for HIA in the new EU Public Health Programme and the linkage between a broad range of Community competencies and health in the Amsterdam Treaty should support wider adoption of HIA.
 

3. CASE STUDIES OF HIA IN THE UK AND NETHERLANDS

3. 1 HIA in the UK
In the UK, public health professionals and academics were early advocates for HIA (Scott-Samuel 1996; Birley 1995). However, in the absence of a statutory requirement for HIA to be conducted in specified circumstances, its development has been patchy and fragmented. This is further limited by the division of the UK into four main territories (England, Wales, Scotland and Northern Ireland). In each part of the UK, HIA has developed in slightly different ways, although people engaged in HIA work exchange information and experiences through relevant academic and policy networks common to the whole of the UK.

Figure 3: Comments on HIA by Tessa Jowell MP, [former] Minister of State for Public Health (England, UK)

However, that Government’s early pronouncements on HIA (see Figure 3) (see also DoH Press Office 1998) may have contributed to present tensions among HIA experts in the UK between those for whom the ‘process of HIA’ (including public participation) is of primary importance and those who argue (in the context of an evidence-based culture) that the methods used should be scientifically rigorous.

3.1.1 Factors affecting the use of HIA in the UK
Table 1 shows these factors that were identified by the Welsh Assembly Government as affecting the use of HIA. However, reading of other UK literature shows that these factors are generalisable to England and Scotland.

TABLE 1: Factors affecting the use of HIA and intersectoral working in Wales (adapted from: Breeze C and Hall R. 2002)
 

	POSITIVE/ENABLERS	NEGATIVE/BARRIERS
a.	Recognition of social and economic determinants of health.	Gaps in the evidence base of the interrelationships between policy areas.
b.	Evidence in the links between health and policy areas, and easy access to it.	Misconceptions of ‘HEALTH’.
c.	Examples of how HIA has been applied and evidence of how it has helped/benefits.	Lack of awareness and understanding of HIA.
d.	Strategic use of research funding programmes to expand the evidence base.	Narrow or ‘traditional’ views in some policy areas.
e.	Major change that leads to a ‘shake up’ of government organisations and practices.	Lack of, or outdated, guidance for policy making.
f.	Political commitment to an integrated approach and commitment to follow it through.	Business overload resulting in policymakers concentrating on their own policy field.
g.	Catalysts, including crosscutting themes as facilitators and drivers for horizontal action by policy makers.	Tight timescales of some policy developments.
h.	Systems and processes that facilitate working across policy areas in the early stages of policy development and implementation.	Language and terminology – ‘jargon’ – in different policy areas/sectors.
i.	Organisational structure and size E. g. Assembly is one organisation as opposed to being a series of separate Ministerial departments.	HIA developed as a ‘separate’ theme without thoughts to it becoming part of wider developments in policymaking.
j.	Improvements in organisational culture, dynamics and working practices.	Policy and/or organisational ‘silos’ reinforce vertical structures and hinder horizontal working.
k.	Health featured as high level strategic objective.	Organisations that are static in terms of changing their culture and practices.
l.	Capacity/resources for HIA.	Process failures or lack of processes for screening of policies and programmes for their relevance to health.
m.		Lack of capacity/resources to undertake assessment within the necessary timescales.
n.		Multitude of impact assessment required increases workloads and resistance to impact assessment.

The original table produced by Breeze and Hall appeared to list factors randomly. In consequence, any later attempt to compare and contrast Welsh and Hungarian factors needs to start by looking for categories or groupings of factors.

Drawing, in part, on the capacity building framework for public health developed, tested and applied in New South Wales (Hawe et al 2000, NSW 2000) and relationship of evidence to policy/practice (Nutbeam 2001), the following categories can be identified among the factors listed by Breeze and Hall. These are from the Table 1:
 

In reality, these different categories are interdependent. For example, new evidence may inform policy decisions and subsequent allocation of resources. Or, a policy decision may determine priorities for research funding and hence the type of evidence that is then available to policy makers. In this analysis, policy and political factors appear to be the most significant block of barriers affecting the use of HIA in Wales.

3.1. 2 Lessons from the UK experience
A number of preliminary lessons can be drawn from experience in the UK. These include:
 

3.2 HIA in the Netherlands
Development of HIA in the Netherlands has been more coherent and systematic, particularly in the assessment of national government policy.

The history of the development of HIA in the Netherlands has been well documented (Put et al 2001). Based on expert consultations during 1993-4, the Minister of Health, Welfare and Sport informed the Netherlands Parliament during 1995-6 about the main points of her policy programme. This included developing a methodology for screening policy proposals made by other Ministries and identifying those that might impact on public health. The methodology would also support more in-depth assessment of policy proposals meeting certain threshold criteria with a view to exerting influence during the official preparatory process. (Letters 24/126, No.3 and No 14, Public Health Policy 1995-98).

In 1996, the Intersectoral Policy Office was set up in the Netherlands School of Public Health (NSPH)  in order to coordinate development of the necessary methodology and a sum of 230,000 euro was allocated to implement a plan of action to develop (see Figure 4)

Figure 4: Main objectives of the Dutch Plan of Action to develop HIA in 1995

Since then, the total annual budget for the IPO has increased from 230,000 to 340,000 euros, while the sum allocated for commissioning specific HIA studies has increased from 65,000 to 95,000 euros. The IPO is financed by the Health Ministry but has independent control over its budget.

3.2.1 HIAs produced or coordinated by the NSPH/IPO
Table 2 summarises the range of policy areas covered under the Dutch programme described previously.

Table 2: HIAs coordinated or produced by the NSPH
 

3.2.2 Lessons from the Dutch experience
A number of early learning points can be drawn from review of Dutch material to date:
 

4. SITUATIONAL ANALYSIS IN HUNGARY

Drawing on and sometimes mirroring experiences elsewhere in Europe (see sections 2 and 3 above), this section presents a situational analysis for Hungary. This analysis is based on interviews with key stakeholders, review of documentation and participation in the policy process, particularly relating to attempts to adopt a broader understanding of public health in policy and institutional circles (see 1.2 above).

4.1 Policy context in Hungary (1999-2002)
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 newly elected 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:

4.2 Factors affecting the use of HIA in Hungary
The factors discussed in this section are drawn from interviews conducted with key stakeholders and analysis of documents in order to contribute to a situational analysis of HIA in Hungary. Table 3 summarises these factors.

As with Table 1, the factors presented in Table 3 can be grouped into four main categories for comparative purposes:
 

A quick look at table three shows a considerable number of barriers and far fewer ‘opportunities’ than identified in the UK context. However, not all stakeholders had an adequate overview of the developments listed in 4.1 above most of which may facilitate the introduction of HIA in Hungary.

TABLE 3: Factors affecting the use of HIA in Hungary
 

	POSITIVE/ENABLERS	NEGATIVE/BARRIERS
a.	International policy priority for HIA.	Lack of awareness and understanding of Health and HIA.
b.	New National Public Health Programme.	Public Health is a too complex issue.
c.	Political commitment to the use of HIA.	An insufficient evidence base in HIA.
d.	The need for regionalisation and decentralisation together with the opportunity to the use of HIA in regional decision making.	The lack of political commitment to follow through policy announcements.
e.	Institutional development in the Ministry of Health and a new National Institute for Health Development.	Unwillingness to really address required system level and organisational level changes, together with immature political culture.
f.	EU accession in terms of potential collaboration with foreign partners in HIA project.	Lack of policy process and strategic thinking and short term interest conflict with long term development.
g.	Possible interest in the Ministry of Finance to consider use of HIA to identify and assess health ‘cost’ of policy proposals from spending Ministries.	Public Health is not an issue in politics.
h.	Stakeholders interested in HIA.	Lack of political and professional consensus in Public Health Policy.
i.	Other approaches to evaluate health impact.	There is discrepancy between policy and research.
j.		Key stakeholders don’t share information and don’t work in teams.
k.		Immature programme management, unclear responsibilities, weak accountability, poor performance.
l.		There is no partnership between health and non-health sectors for HIA, and weak intersectoral working for health.
m.		Conflicting interests in HIA.
n.		Lack of capacity (institutional. Human resources, working examples, guidance or training materials) for HIA.
o.		Weak social capital (trust, confidence) for participation in HIA project.
p.		Lack of legal framework for HIA.
q.		There is too little time available for HIA before decision making.

4.2.1 Opportunities in Hungary
a. There is increasing recognition by governments of the importance of HIA and the needs for international collaboration in order to share experience, best practice and learn from each other. This is reinforced by the Article 152 of The Amsterdam Treaty for Member States of the European Community and the World Health Organization’s Health 21 policy framework for countries in its European region (Pan-European HIA survey, 2002).

b. The government accepted a new National Public Health Programme in December 2002 for the next decade. One of the priorities in the Program is capacity building for health development including capacity for HIA.

c. The newly elected Socialist/Free Democrat coalition Government says that it is interested in and committed to the use of health impact assessment and it is a priority to develop capacity for HIA.

d. The necessity of decentralisation and regionalisation is intended to re-allocate power more appropriately between national, regional and local levels. That should happen in Hungary in the context of EU accession. The EU will allocate resources for regional development and Hungary needs to prepare it’s infrastructure for this. That will open up the regional level of decision making, governance and program delivery, This will provide a new arena for the application of HIA in decision making processes.

e. The national government established a new Division for Public Health in the Ministry of Health, Social and Family Affairs, and recently accepted a new National Public Health Programme. The Program will have a new background institution for policy analysis-advice, program management and health development. Capacity building for Health Impact Assessment and co-ordination of the related tasks is intended to become a new function of this Institute.

f. EU accession opens up a new perspective for Hungary in terms of development of the use for HIA. For example, through collaboration opportunities with EU partners. Participation as a third party in the SANCO project would provide valuable experience, knowledge and importantly, potential leverage to develop the required capacity in Hungary.

g. Previous discussion involving a Ministry of Finance colleague dealing with social expenditure, showed interest in getting a better understanding of HIA as a step to considering its possible use in identifying and assessing policy proposals from spending Ministries for potential ‘health costs’ and/or ‘added health value’.

h. Interviewed stakeholders and government have positive attitude to the use of HIA and they are interested to develop capacity for it.

i.  At present, the baseline situation in Hungary is a lack of obvious capacity for Policy HIA both within the health sector and outside of the health sector. Some related infrastructure and resources exist for example in the:

4.2.2 Barriers in Hungary
a. There is a lack of understanding or, at best, a passive awareness that:

b. Classical public health with its focus primarily on communicable diseases, secondary prevention and hygiene protection remains important in Hungary. However, an efficient public health effort must focus on helping to reduce inequalities especially as Hungary cannot avoid the impact of modernisation and globalisation. This requires holistic thinking to develop well-rounded and appropriate solutions.

c. The evidence base to support HIA is lacking or insufficient and its application is missing or not appropriate. There is a perception that Public Health research is very weak in Hungary and there is a serious lack of resources. The evidence base, concepts, models and examples that would help Hungary modernise its approach to Public Health is mostly in English and available only for those who can read it.

d. There is often a lack of follow-through from political commitment to implementation in Hungary. There may be several reasons for this. First, politicians gain profile simply from announcing policy initiatives and do not seem to be so interested in what happens afterwards. Second, there can be a lack of obvious mechanisms by which policy can be translated into action.

e. After the political, economical and social changes Hungary is still in the process of transformation. Based on my interviews with key stakeholders and research experiences there is a very real unwillingness to address the need for system and organisational level changes. This is made worse by a still developing pluralistic political culture, disempowered institutions and civic society and, at a basic level, concerns about job security in a period of significant change. At the same time EU accession and developmental needs will require new ways of working, new knowledge, skills to fulfil expectations.

f. Since 1989 Hungary had at least 6 National Public Health Programme and basically no implementation so far. There was no clear strategic view about public health and no proper planning for implementation or institutional development. Within one national governmental cycle we had several ministers, new organisational structures and functions, new management or no management. At the same time short term interests of people within a rigid bureaucracy are barriers to long term development.

g. Public Health comes up the political agenda during the last election campaign but seems to fade away after the election, being overtaken by more pressing reactive/emergency concerns.

h. Mirroring other factors mentioned above, stakeholders don’t share information, and in only a few areas (such as drug prevention) is there obvious partnership working.

i. As happens elsewhere, policy and research have different speeds and natures. The lack of commitment to evidence-based policy and practice does not provide supportive conditions for using research in decision-making at policy and practice levels. Policy sometimes seems to be designed as much as a means of spending the Government’s short-term budget as it is of addressing basic challenges facing the Government (wealth creation, social inclusion, public health, democracy).

j. Related to point ‘e’, the working culture within the health sector and especially within key organisations in the public health field is based on an out of date command and control approach combined with a strong sectoral, rather than intersectoral orientation. It appears that the past 10 years of transition have reinforced this culture causing organisations and individuals to be afraid and suspicious to share information and to want to work in teams.

k. In the public health field program management skills are under-developed, responsibilities are unclear, the accountability of programmes is weak and performance is poor or not well measured. One of my interviewee told me that “people are not following roles and regulation in the Parliament either” (for example the enforcement of the  No Smoking in Public Places Law).

l. Hungary has experience of intersectoral working (World Bank Health Programme projects, Healthy Cities and Regions for Health Networks) but have not been able to successfully institutionalise this. Working in partnership with each other requires new way of thinking and application of new approaches, methods, tools, etc. Health Impact Assessment potentially provides a concrete and practical way of increasing commitment by health and other non-health sectors for better health and quality of life for people.

m. There are different stakeholders and institutions in different policy proposals and programme and they can have conflicting interests to carry out HIA.

n. To date, Hungary has not identified clear institutional responsibility for coordinating the development of expertise and knowledge in HIA including the production or/or translation of specific guidance or training documentation on health impact assessment.

o. Social capital (trust, confidence, knowledge) between agencies and individuals is weak in Hungary. A paradox of the Socialist period is that it undermined social capital and replaced it with a system of state dependency and patronage. Hungary is still passing though its transformation and it may still be too early after the system change for significant levels of social capital to have developed again. As HIA and similar participatory techniques become more widely used and familiar it may help lead to develop strong confidence and capabilities in represent broader stakeholder views in the development of policy and programmes.

p. Hungary has a regulation for social, economical and environmental impact assessment, but no law for HIA.

q. Sometimes there is too short time for any impact assessment before decision making. This reality is, in part, responsible for scepticism for using methods like HIA that ‘delay’ decision-making. What does not seem to be appreciated is that HIA and similar policy-planning tools can help improve the quality of policy decision making and, in consequence, improve the effectiveness and relevance of measures to implement policies.
 

5. COMPARISON OF FACTORS AFFECTING THE USE OF HIA IN HUNGARY AND THE EU

In the UK there appears to be a critical mass of factors at a policy level that will help promote wider adoption of HIA and related methods at Institutional and other levels. By contrast this critical mass has not yet been achieved in Hungary. In part this may be because of a lack of a broader modernisation agenda for Government/public administration of the kind seen in the UK and elsewhere. Hungary has a lot of developmental needs to deal with all the barriers in relation to the application of HIA methodology. Capacity building means working on several levels: political, strategic, (inter) institutional and training.

Learning from the Scottish experience shows that several actions need to be taken in order to have a real chance for developing health impact assessment and making healthy public policy:
 

Evidence
The Welsh study found 4 factors supportive of the use of HIA while none were mentioned by Hungarian stakeholders. In Wales and the UK generally, there has been for some years a political and policy supported drive for evidence-based decision making. In turn, this has helped to generate funding for applied research that can be used to support decision making. This situation is not the case in Hungary at present. A problem is that much work on HIA is published and reported in English but English language (and other foreign language) skills are not widespread in public administration. Without either improving English language skills (as is being done in the Military following joining NATO) or making this English evidence base available through significant investment in translation, Hungary can’t take advantage of this investment and learning from abroad.

Political/Policy
The political/policy factors are the most significant category of barriers in both countries. However, the nature of negative factors is different in Hungary than in Wales. In Hungary the main problems are the lack of a transparent policy process, political commitment to follow through policy announcements, limited means for exploring and making consensus among sectors and stakeholders around shared policy priorities, unwillingness to address system and organisational level changes, discrepancy between policy and research and no priority for public health. In contrast Wales has the following barriers: narrow views in some policy areas, lack of policy guidance, business overload, tight timescales, terminology jargon and HIA is not a part of decision making. Positively, in both countries there is a political commitment to the use of HIA and major changes in the policy environment are supportive factors as well. There are other differences between the two countries. In Hungary international and national level policy priorities are positive contributors, while in Wales HIA, as a crosscutting catalyst for horizontal action, and systems and processes that facilitate working across policy areas are enablers to the use of HIA.

Institutional
Institutional factors as barriers are almost equally important in Hungary and Wales as well, but as enablers it is more significant in Wales. Critically, the Welsh Assembly Government supports the use of HIA in decision making, among policy implementation agencies health is a high level strategic objective and different improvements at organisational level are being made. In Hungary, the Ministry of Health, Social and Family Affairs established a new division for Public Health and they have an intention to re-establish a new National Institute for Health Promotion in Hungary. These developments can be supportive to the use of HIA at national policy level.

In both countries, important barriers include: weak horizontal working for health and organisational unwillingness to change cultural and working practices. In Wales one additional problem is the apparent failure of processes to screen policies for their relevance to health. In Hungary immature program management, unclear responsibilities, weak accountability, poorly monitored performance and conflicting interest in HIA are all barriers to the use of HIA.

Resources
This category is more significant determinant both as enablers and barriers in Hungary than in Wales. The Hungarian study found 4 – 4 factors as opportunities and barriers to the use of HIA. Among the opportunities are EU accession, interest among stakeholders and Ministry of Finance interest in HIA and other approaches to evaluate policy proposals submitted by spending Ministries. Among the barriers there are the lack of capacities and legal framework for HIA, weak participation and too little time availability before decision making. In Wales capacity and resources for HIA are enablers to the use of HIA, while too little time before decision making and increases workloads are barriers to the use of HIA.
 

6. CONCLUSIONS AND POLICY RECOMMENDATIONS

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 this research the following areas should be addressed in developing action at political, institutional and professional levels
 

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

More specific policy recommendations will be addressed in a parallel policy briefing paper. The main recommendations are given below.

6.1 Establishing a legal framework for HIA in Hungary
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.

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 (meeting on the topic: on the Hague conference, 17-23 2002). 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.

6.2 Building capacity
The Hungarian Government should develop mechanisms to consider health in national policy making, and to support this at all levels. The assessment of 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 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 New National Public Health Program, which would be responsible for supervising a Unit dealing with supporting the implementation and use of HIA in Hungary.

6.3 Institutional development
An independent Research and Development or Health and Public Policy Unit has to 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 a frame of a civil organization in order to have opportunities to get resources not only from the government. This civil organisation should 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 advises on those policies which have to be examined concerning their potential impact on health, supports screening within the relevant Ministry and where necessary conducts or commissions full HIAs. The results are communicated to 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.
 
 

7. REFERENCES

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