Margit Ohr, IPF 2003-4 Interim Report

2003-4 IPF Project

2002-3 IPF Project

Margit Ohr – Interim Research & Policy Paper, February 2004

Interim Research and Policy Paper

HUNGARIAN HEALTH IMPACT ASSESSMENT PILOT PROJECT

[download Research and Policy Paper in PDF, 120KB]
[Diagram 1: HIA Pilot Project timeline in PDF, 60KB]

Introduction

Article 152 of the Amsterdam Treaty says 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[1].

In this context, Health Impact Assessment is recognised and supported by the European Union as a critical competency for national governments to master and apply in their own jurisdictions. The Gothenburg Consensus Statement (1999) defines HIA as

a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.

Consequently, the use if HIA has become more widespread among member states. However, in most accession states, including Hungary, HIA is untested although most have several years experience of environmental impact assessment (EIA). In this context, this interim paper describes the development and processes of the HIA pilot project. This is very much work in progress. The final report will include a more thorough analysis of project implementation, outputs and outcomes.

Purpose of Pilot Project

Building on an earlier IPF project (Ohr 2003) that looked at opportunities and barriers to HIA in Hungary, the purpose of the pilot project described below is to undertake a HIA of a selected national policy in order to promote understanding in and confidence of HIA in Hungary. This will be achieved by engaging a range of key stakeholders in the pilot project and by careful documentation of the processes and outcomes of the HIA. The pilot project should: (i) show if HIA is a feasible and effective tool that enhances the policy process (ii) suggest improvements to the design and conduct of HIA that will increase its utility in an Hungarian context (iii) help identify ways in which existing policy processes might be enhanced to facilitate HIA.

Once all stages of the project have been completed it is expected that the participating stakeholders will work together to ensure that

the case for HIA is appropriately championed at Ministry and cross-Ministry level
guidelines for commissioning and using the results of HIA are agreed and disseminated
futher resources are commited to enable the development of capacity to deliver HIA through academic, commercial and Government organisations.

Relevance to EU Accession and the Public Health agenda

The new EU Public Health Programme (2003-2008) was implemented on 1 January 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:

to improve information and knowledge for the development of public health
to enhance the capability of responding rapidly and in a coordinated fashion to health threats
to promote health and prevent disease through addressing health determinants across all policies and activities.

To accomplish these objectives the Programme is intended to contribute to:

ensuring a high level of human health protection in the definition and implementation of all Community policies and activities through the promotion of an integrated and inter-sectoral health strategy
tackling inequalities in health
encouraging cooperation between Member States in the areas covered by Article 152 of the Amsterdam Treaty

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.

It is recognised that the assessment of the health impacts of policies at national and regional level should be a priority since the achieved effects are more fundamental and resource efficient than confining assessment at local or program level. However, despite growing investment in and understanding of HIA methods and tools 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, a pan-European survey of health impact assessment at national government level was undertaken. The survey, which covered EU member states, accession countries 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.

Work in Hungary by Ohr (2003) took the main themes of this Survey and case studies of HIA in the UK and Netherlands as a starting point for exploring the opportunities and barriers to the use of HIA in Hungary through interviews with key stakeholders.

Circumstances and context effecting pilot project implementation

The assumption informing the original research (Ohr 2003) 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.

In brief summary, the research found that:

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.

HIA has now been institutionalised by the Ministry as a specific Division for HIA within the reorganised National Institute for Health Development (OEFI). In delivering its remit for HIA, the Institute recognises that 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 of HIA in Hungary. The pilot project has been enabled by support from the Continuing International Policy Fellowship Program used in combination with the HIA Division of OEFI. In essence, the Continuing Fellowship has provided an opportunity to use formal (structures and procedures) and informal (contacts and networks across Government) means to move forward and advocate for the pilot study.

Risk assessment

Taking into account the above context, a risk assessment was conducted taking into account those factors that are outwith the direct influence of the project but that could impact on the project. These factors are identified in the table below along with possible ways of managing these factors.

CHALLENGES	SOLUTIONS
Timescale pressure due to delays in accessing correct individuals in partner organisations and securing appropriate information	Engage stakeholders early in process to secure access to targeted people and information
Diffuse expectations of outcomes due to unclear boundaries related to objectives of the study	Early discussion with Ministry/PMO about their expectations of outcomes and agreement of ToR with key stakeholders
Danger of disparate workstreams due to complexity of investigation and analysis	Consistent and robust project coordination and integration of all activities, to secure focus on key objectives
Non availability of required information and data for meaningful analysis	Early detection of potential impact and negotiation with key stakeholders
The cross organisational challenges of implementing actions are too challenging for those organisations locked into silos	Secure cross organisational Project Advisory Group (PAG) of sufficient seniority to enable and enact on planned actions and sustain a tangible impact
Without a legal framework, stakeholders (including Ministries) may be inclined to ignore HIA	The PAG should include legal expertise to help prepare recommendations relating to development of an appropriate legal basis for HIA
Stakeholders focussing exclusively on healthcare, and/or, on a one-directional impact of healthcare	HIA provides a concrete and practical way of increasing commitment by health and other non-health sector actors to improving health and quality of life for citizens

Taking these factors into account the pilot project objectives were identified and discussed with colleagues. These become the basis against which the success of the pilot project can eventually be evaluated.

Project objectives

To work with senior staff at the Ministry of Health, Social and Family Affairs and Prime Minister’s Office to identify an emerging national policy that would be appropriate as the focus of a pilot HIA.

To coordinate the design and delivery of the pilot study with input from key stakeholders.
To coordinate delivery, analysis and reporting of the findings of the study including detailed recommendations for operationalising HIA in the policy process across all Government ‘spending’ Ministries.
To conduct a developmental evaluation of the pilot project that assesses the feasibility of the HIA process.
To maintain commitment to and implementation of other relevant activities that will be necessary to ensure the longer term relevance and sustainability of HIA in Hungary.

Issues in project development and implementation

This section deals with issues that are relevant to the setting up of the project including ensuring that a range of stakeholders are engaged to support the project and getting around the problem of a continuing lack of a robust institutional budget for HIA.

Engaging stakeholders

The benficiary of this pilot project will be the Hungarian Ministry of Health, Social & Family Affairs (MoHFSA). The Ministry will be expected to advocate for the wider sustainable adoption of HIA across government.

The relevant stakeholders and the rationale for their inclusion are provided in the following table:

Stakeholder	Relevance
MoHSFA	The Government acknowledges the importance of health-driven policy. The Minister (Dr. Kokeny M) attaches high priority to starting to develop and implement HIA in context of EU Accession. The Ministry has approved plans for a national HIA pilot to be conducted by Ohr with OEFI.
OEFI	The reorganised National Institute for Health Development includes a new Division for HIA Capacity Building. Among Divisional work tasks approved by the Ministry are (i) organisation of a national conference (December 2003) on HIA with input from international speakers to raise awareness of HIA among stakeholder groups (ii) run this national pilot project
Prime Minister’s Office	As declared by the Amsterdam Treay, health is a cross-cutting compentency for governments of EU member states. The PMO drives cross-cutting policy agendas and defines relevant strategy.
Ministry of Environment	This Ministry has several years experience in conducting and developing capacity for EIA. Although the methods can differ, the pilot project would benefit from the experience that can be shared both with the conduct of the pilot project and with subsequent mainstreaming of HIA across Government.
ANTSZ	OEFI is part of this national service. It would be appropriate for ANTSZ to develop understanding of and commitment to support the wider adoption of HIA.
National School of Public Health, Debrecen	The School at Debrecen is a centre of methodological expertise in public health and a main provider of post graduate training and professional development in Hungary. As such, it is an important resource for developing Hungarian-based training in HIA in the medium term rather than relying on international expertise.

Apart from the Prime Minister’s Office senior representatives from all the above stakeholders took part in the First National Hungarian Conference on HIA in December 2003. However, the Conference was also valuable in engaging a wider range of stakeholders and in raising the profile of HIA with representatives from the mass media.

Other issues relating to engagement of these stakeholders are that:

The MoHSFA/PMO will be asked to address any high-level protocols relating to the identification of a national policy (outwith the Health Sector) to be subjected to a HIA.
Members of the PAG will be asked to actively contribute to the work of the PAG including
Attending all PAG meetings
Agreeing the role of the PAG
Agreeing the final project terms of reference (ToR)
Reviewing and providing constructing comment on interim and final project reports and other outputs
Acting as champions of the project in communication with other stakeholders.

Subsequently, the Minister of Health advised that it would not be necessary to formulate a different body (National Steering Committee) for the National Pilot as suggested in September. Instead, he suggested that the Intersectoral Ministerial Committee for Public Health would take on this role. For this reason I was working closely with the Ministry in order to ensure high level political commitment to the whole process. However, the PAG mentioned above can still operate as a professional advisory and reference group for the pilot project

Focusing the project

During the first National Conference (and satellite EC workshop) we had identified a number of potential ideas of national policies for HIA scrutiny. The Ministry of Health, Social and Family Affairs has to make the final decision on the subject of the Pilot Study.

Resourcing the project

The emerging problem is the lack of resources to pay for international expertise and organise training for how to conduct the actual assessment. This is set against a backdrop of a reported deterioration in Government finances including a 3 billion Hungarian Forint deficit in the budget of ANTSZ. To manage this situation in te short term, colleagues have been enlisted to develop a set of HIA case studies for a case study seminar being organised for February. The purpose of this exercise is to try and develop internal methodological support for the National Pilot Study. The case studies take concrete examples of HIA in other EU and Accession States and seek to highlight the key processes, outcomes and lessons learned.

Phasing and workplan

Diagram 1 below shows the phasing of key elements of the pilot project and time schedule taking into account the importance of sustainability of required project results.

Anticipated project outputs

The main anticipated outputs of this study are intended to be:

better understanding of the practicalities of conducting a HIA among members of the Project Advisory Group, project staff members from OEFI and the wider Networks with whom project findings will be shared
building confidence and skills in HIA among project participants
writing up the pilot project as a detailed case study to guide future HIA work
developing guidelines for conducting HIA in a Hungarian context
recommendations for operationalising HIA across Government Ministries
commitment by MoHFSA and Prime Minister’s Office to champion wider phased introduction of HIA across relevant Ministries.

Diagram 1: Design and delivery of HIA pilot project timeline [PDF 60KB]

[1] 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.