Mark Harris, Andrew Knight and I published a paper in the Medical Journal of Australia. It’s an update of a review of the management of chronic conditions in Australia, ten years on. What was surprising to me is that we haven’t made too much progress has in the obvious areas – integrated care, information sharing, multiple provider care plans. Many of the promising activities that have emerged over the past decade have been at the individual and practice level. For example, using peer navigators, and tailoring care to people’s literacy and activation levels.
The table below suggests some potential solutions, but these are only some of them.
Every year Sydney Local Health District holds EquityFest, an event that showcases work being done to address health equity within the District and to consider what else needs to be done. The theme of this year’s EquityFest was “investing in the future – leaving no one behind”. It was an impressive showcase of the diversity of the District, and the work that they’re undertaking to respond to their communities’ needs.
More than that though, it provided a clear statement that equity matters to them as an organisation, something that we almost never see in contemporary Australian social institutions.
There’s a need to invest meaningful time in understanding lived experience, not just giving lip-service to it through a narrow focus on things like patient experience measures.
Reflective and interrogative practices are required, personally and organisationally, to identify biases and to think about who’s excluded in, and through, our activities.
We need to think about “soft infrastructure” more meaningfully and systematically in planning (referring to services, networks, and community social assets), and sharing this through networks/backbone organisations.
There is a groundswell of interest in equity, but the challenge is developing a shared vision of how to achieve it, being accountable for change, and the related challenge of meaningful engagement.
There was a welcome from the Chief Executuve Dr Teresa Anderson and a warm welcome to country by Uncle Allen Madden.
A/Prof Jane Lloyd from the Health Equity Research and Development Unit gave an overview of the importance of social inclusion, and the health harms of exclusion. She spoke about who’s excluded in Australia, based on data from the Brotherhood of St Laurence Social Exclusion Monitor. This highlighted that people living in public housing, people who are homeless, people with substance use disorders, sex workers, and people in custody all experience extremely high levels levels of social exclusion.
Peter Jack from Sydney Local Health District spoke about his experiences of working with people in Redfern and Waterloo about health concerns. In discussion with Jane he reflected on life, growing up as an Aboriginal person and the challenges of working with people who are socially excluded in Sydney and Adelaide. The lessons I took from from Peter were the importance of investing time to develop credibility and trust with excluded people, before we try to do anything else.
Zione Walker-Nthenda spoke about the challenges of inclusiion in justice and domestic violence. She emphasised that self-interrogation is important, both organisationally and institutionally, to identify biases and barriers to inclusion. Essentially, that we need to constantly check that we’re not kidding ourselves about how inclusive we’re being.
Liz Harris from HERDU presented a framework that emphasised the need to consider place as the dynamic interplay between people and space – meaning the norms, use, services, and culture that make up the bulk of community life. Her critique was that in planning in human services often focuses on “need”, constrained to understanding people in atomised ways, and rarely considers place assets and issues in meaningful ways. She further suggested that more work is required to develop coherent program logic for these activities.
Hal Pawson from the UNSW Faculty of the Built Environment spoke about the factors that drive locational disadvantage. The drivers he emphasised were:
pushing people without resources to the fringes, or less accessible parts of cities
the diminishing pool of low cost housing in acccessible areas
a political unwillingness to use planning powers to reverse these trends.
Pam Garrett, Director of Planning within SLHD, spoke about the scale and pace of development within the inner west, ranging from Green Square, through to Waterloo/Redfern, Parramatta Road, and the Bankstown line. This represents a challenge in general, but also presents specific challenges to the District to make sure that services are responsive and that health inequalities aren’t exacerbated.
Geoff Turnbull from Inner Sydney Voice and REDwatch emphasised the need to get back to genuine community development, and the need to work in genuine partnership with communities. He emphasised the need to create organisations that bring together interests to have a voice in changes that would affect their suburbs and communities.
I wrote a piece for Croakey on the first of the 2016 Boyer Lectures, which focus on the social determinants of health. The four Boyer Lectures air weekly from Saturday 3 September 2016 at 1pm on Radio National, or you can subscribe to the podcast.
“One thing leads to another.”
This was the secret of life imparted to Michael Marmot by a patient, and recounted as part of the opening 2016 Boyer Lecture Fair Australia – Social Justice and the Health Gap. It could also be the theme of this year’s lectures.
In his first lecture, Marmot set out a compelling argument for the links between the circumstances of one’s life and work and health outcomes. These circumstances are socially determined and not equally shared, as shown by his foundational research on the social gradient in health.
This is familiar territory for most Croakey readers, and the information wasn’t new. It was well-crafted however, and drew on evidence, comparisons and anecdotes. Marmot led the audience, inexorably, from the problem of health inequalities, to their causes, then to the changes that are required to address them.
One thing leads to another.
The points in the lecture that resonated most with me were:
Health status is a better indicator of wealth than GDP
Marmot cited the example of Costa Rica, who have invested heavily in education. He outlined the benefits this has brought to their health and national development, in ways that aren’t captured by GDP and conventional economic measures alone.
This reminder that health is a meaningful and under-recognised indicator of wealth and assets is timely given the publication of Clare Bambra’s excellent Health Divides: Where you live can kill this week. It’s destined to become a seminal work on the political geography of health, but it also puts forward several creative ways of presenting data on health inequalities.
My favourite idea is a European Health Championship, modelled on the European Football Championship. Health League
In a sporting nation like Australia, this sort of approach could get attention.
Imagine if we competed internationally to have the best health. Imagine if successfully reducing the gap in life expectancy between Indigenous Australians and non-Indigenous Australians became a source of national pride.
Marmot emphasised the role that empowerment, or lack of empowerment, plays in determining people’s health. He drew on the framework for empowerment developed for the WHO Commission on the Social Determinants of Health. This emphasises the need for material, psychosocial, and political empowerment if people are to take control of their health and have the same opportunity for good health.
Using data to drive change
Marmot gave the example of Coventry in the UK, who describe themselves as a “Marmot City”. They have established monitoring and reporting frameworks to drive activity on health inequalities. Accountability has enabled sustained action and a better understanding of the issues.
In Australia, many services have been working on the same issues. South Eastern Sydney Local Health District has incorporated a set of comprehensive indicators of health inequalities into its Equity Strategy. Data enables action to move beyond rhetoric.
A different audience
The value of the Boyer Lectures is not their ability to preach to the converted. It’s about exposing an engaged audience to new ways of thinking about Australia’s future, and in that task last night’s lecture succeeded.
Eva Cox’s 1995 Boyer Lectures on A Truly Civil Society were instrumental in sparking a wave of interest in social capital in the design and evaluation of social support in Australia during the mid ‘90s. Eva herself would say the tide has gone out on social capital, but its impact is still felt.
The research program I manage includes a stream on place-based interventions to address health inequities. As part of this we have collected neighbourhood-level data on trust and social capital in disadvantaged areas in South Western Sydney since 1998. This research can be directly traced back to the agenda set by the 1995 Boyer Lectures, and informs and guides our work to this day.
It’s my hope that this year’s Boyer Lectures may have a similar catalyst effect.
The remaining lectures will focus on the importance of early childhood, our work and living conditions, and the action required by researchers, civil society, and government.
There is a series of articles at The Conversation on the themes covered by this year’s Boyer Lectures, featuring contributions from Sharon Friel and Fran Baum.
Hopefully this will lead to a broader appreciation of the social gradient in health in Australia, and a shared understanding of the case for action.
One thing leads to another.
To coincide with the Boyer Lectures, Croakey has also released a collection of articles on the social determinants of health. Includes contributions from Fran Baum, El Gibbs, Liz Harris, Sharon Friel, Tim Senior, Marie McInerney, Marilyn Wise, Peter Sainsbury, Denis Raphael, Fiona Haigh and many others, including me. Recommended reading.
Last week I attended the final day of a Learning by Doing health impact assessment (HIA) training program. Learning by Doing is a structured six-day training program run by the Centre for Health Equity Training, Research and Evaluation (CHETRE), where I work. The training is broken up into distinct stages. People learn about HIA, go away and do the steps they’ve learned about, then come back to reflect and learn about the remaining steps.
Some of the stand-out lessons from the Learning by Doing sites were:
A lot of the value of HIA lies in highlighting and clarifying assumptions made during planning.
A planned engagement approach is useful as part of all HIAs.
Conceptual learning remains an important outcome of HIAs, in particular learning about health equity.
Involving consumers in HIAs has multiple practical benefits, such as identifying alternatives and providing an understanding of context and history.
Scoping remains as critical as always – being rigorous but not biting off more than you can chew (it also reminded me of this paper about scoping in EIA).
Not all barriers can be overcome; you need to be realistic about what you can achieve within the limits of an HIA.
More on Learning by Doing
For more on CHETRE’s work on health impact assessment go to HIA Connect. The Learning by Doing approach is described in greater detail in the chapter below:
Harris E, Harris-Roxas B, Harris P, Kemp L. “Learning by Doing”: Building Workforce Capacity to undertake HIA – An Australian case study, in O’Mullane M (ed) Integrating Health Impact Assessment into the Policy Process: Lessons and Experiences from around the World, Oxford University Press: Oxford, 2013, p 99-108. ISBN 9 7801 9963 9960 Google Books link
I’d be interested in any feedback. In particular I’d appreciate any responses to what I think remains unknown/future directions for HIA evaluation research:
How does HIA change perceptions at individual and organisational levels and how can we better account for this through research design?
How can we better evaluate learning that can occur through HIAs, at individual and organisational levels?
Social (Glasbergen, 1999)
How can we account for different forms of bias in evaluations of HIA?
Narrative fallacy (Harris-Roxas et al 2014)
How can we develop a more nuanced approach to scoping HIAs to consider the determinants of health inequities, as distinct from the determinants of health?
Source: Harris and Harris-Roxas 2010
“What is clear here is that impact assessment is beginning to be seen not just as a tool for informing and inﬂuencing decision-makers, but as a process which changes the views and attitudes of stakeholders who engage with the process such that their own attitudes and practices change outside of the immediate decision making context. That is, the inﬂuence of impact assessment processes may extend well beyond the narrow decision window in which they operate. There is also recognition that such learning operates on an institutional and social level as well as on an individual level.” Bond & Pope (2012:4)
Bond A, Pope J (2012) The State of the Art of Impact Assessment in 2012, Impact Assessment and Project Appraisal, 30(1): 1-4. Download PDF
Glasbergen P (1999) Learning to Manage the Environment in Democracy and the Environment: Problems and Prospects (Eds Lafferty W and Meadowcroft J), Edward Elgar: Cheltenham, 175-193.
Harris E, Harris-Roxas B (2010) Health in All Policies: A pathway for thinking about our broader societal goals, Public Health Bulletin South Australia, 7(2): 43-46.
Harris-Roxas B, Haigh F, Travaglia J, Kemp L (2014) Evaluating the impact of equity focused health impact assessment on health service planning: Three case studies, BMC Health Services Research, 14(371), doi:10.1186/1472-6963-14-371. www.biomedcentral.com/1472-6963/14/371
HIAs provide an opportunity to advance equity. Practitioners often struggle with how to effectively communicate about equity in HIA, and strategically communicate about this core value of HIA. An effective approach to communication is fundamental to ensuring that HIAs can impact policies and support change.
This guide intends to aid HIA practitioners in their efforts to communicate about equity as an essential step towards advancing equity.
Whenever I used to write anything about health impact assessment I started with “HIA it is a new field”. That’s no longer the case. People have been grappling with how to make HIAs routine for more than twenty years. This has taken different forms. It’s described as institutionalisation, mandating, capacity-building, integration, harmonisation and even theoretical alignment. People have often conflated quite different HIA activities as the same thing, complicating things. This led to people talking at cross-purposes.
How to make HIA part of routine practice is really none of these things. It’s about how we get HIA to the next level?
The next level?
What do I mean by this? The next level represents deeper embedding in routine practice. A more sophisticated understanding of when HIA can be useful. A large enough body of practitioners with varying levels of experience.
These challenges apply within countries but also globally.
How do we get from where we are to this next level? We have describe what the current state of practice is (this varies). We also have articulate what our desired future state would be. And then we have to describe what steps lie between.
Maturity models can help us.
Maturity models are quality improvement tools that were first used in information technology. ‘Maturity’ referred to the optimisation of processes, including changes from ad-hoc to formalised arrangements and ongoing quality improvement. This involved describing different levels of maturity across several different domains.
The different domains in a maturity model are usually rated for their maturity:
initial – involves individual heroes, is not well documented and hard to replicate
repeatable – processes are well enough described or understood that they can be repeated
defined – the processes are defined and confirmed
managed – the processes are managed in line with agreed metrics
optimising – process management includes ongoing optimisation and improvement.
In some cases a sixth level is added. This involves embedding capability across all processes.
What would HIA maturity models include?
HIA maturity models would enable us to think about which domains of maturity matter. These could include:
resources and tools
I think use of maturity models would enable more sophisticated thinking about capacity building. It would enable discussions to move beyond their historical focus on regulations and workforce. I’ve attempted to pull together a draft HIA maturity model below.
This model isn’t perfect and it won’t be applicable in all settings. It will need to be adapted, changed and maybe even started from scratch. I hope maturity models like it will enable a more nuanced way of thinking about the domains of capacity that are required and to focus activity and investment.
Maturity models give systems, organisations and HIA practitioners a better framework for understanding the range of capabilities that we need for HIA to flourish. HIA maturity models would identify:
the domains of HIA capability
provide a basis for appraising HIA capability, development and performance
describe the characteristics of different levels of HIA capability
provide a description of what enhanced capability and practice would involve.
I think maturity models represents a promising area of practical and conceptual development for HIA. I’m interested in what you think.
This ebook describes the use and evolution of health impact assessment (HIA) and EFHIA internationally and in Australia, how it has been used in relation to health service plans, examines its effectiveness and impacts on decision-making and implementation and examines several EFHIAs using case study and interpretive description methodologies.
This research shows that EFHIA has the potential to have both direct and indirect impacts on health service planning. These impacts are influenced by a broad range of factors however. The case studies in this ebook show that engagement with the EFHIA process and the extent to which EFHIA is regarded as a broader learning process are important factors that mediate the extent to which EFHIAs influence subsequent activities.
This research suggests that it is not possible to adequately describe the full range of impacts of EFHIA on decision-making and implementation without looking at perceptions about EFHIA’s effectiveness, in particular the perceptions of those involved in the EFHIA and those responsible for acting on its recommendations. These perceptions change over time, suggesting that future research on the effectiveness of HIA should look at the mechanisms by which this change occurs.
The ebook makes two theoretical contributions in the form of (i) a typology for HIAs and (ii) a conceptual framework for evaluating the impact and effectiveness of HIAs. This conceptual framework is tested for its applicability and refined.
The ebook and the accompanying publications were written to fulfil the requirements for a Doctor of Philosophy in Public Health at the University of New South Wales.
I’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 3 of the Consultation, there are also posts on Day 1 and Day 2.
Workshop 3: Review of Urban HEART guidance
There was a widespread view that the current Urban HEART guidance works quite well but that there are a few areas where it might be enhanced. There was discussion about the selection of interventions and responses being difficult in practice, and that it involves considerable negotiation. There wasn’t agreement about the best ways to reflect this in the guidance but it was a recurrent theme, and one that’s familiar in the context of HIA and negotiating recommendations.
Community participation is another aspect of Urban HEART that has been difficult to provide guidance on. Participatory rapid assessments, health assemblies, surveys, workshops, and the use of mobile and electronic engagement tools were all discussed as ways to involve communities in Urban HEART processes, though these were all recognised as having limitations.
There was quite a lot of discussion about the extent to which HIA might be integrated into Urban HEART, though it was agreed that Urban HEART and HIA are complementary rather than being processes that could be integrated. This is because Urban HEART helps to identify needs and areas for action at the city level, whereas HIA is most useful where there is a proposal or a limited set of options to assess. So whilst there are procedural similarities they serve quite different purposes and integrating them might complicate things rather than helping. The diagram below from the Urban HEART User Guide shows how WHO conceptualises Urban HEART’s role in local planning cycles. Some related procedures like multi-criteria decision analysis and equity lenses were also discussed, and how they might be integrated into Urban HEART.
An important issue that was discussed was that we need to focus on enhancing the equity focus of Urban HEART rather than simply improving the technical aspects of the process. The value of Urban HEART is its equity focus rather than its health focus, and we need to prioritise that in any revisions. This is something I hadn’t really considered before and I think it poses a challenge to the HIA practitioners: beware focusing on improving technical aspects of the assessment process at the expense of an equity focus. Technically perfect assessments won’t necessarily result in inequities being better addressed.
The need to demonstrate economic effectiveness/cost-benefit was also discussed. This is familiar territory for HIA practitioners! I confess that I have mixed feelings about this. Whilst I can see that there are benefits to even limited economic approaches to describing the economic benefits of HIA or Urban HEART (willingness to pay analyses, estimated savings based on case studies, etc), ultimately Urban HEART and HIA are about informing and improving planning and decision-making. They’re not readily comparable to other health interventions because they’re fundamentally different types of interventions.
The need for an online guide, repository and clearinghouse for evidence was discussed. We’re very fortunate in HIA to have the HIA Gateway. The consensus was that something similar is required for Urban HEART.
City case presentations
Madeleine Ntetani-Nkoussou discussed the use of Urban HEART in Brazzaville, Congo. There’s a number of issues in Brazzaville associated with informal settlement/slums and rapid urbanisation. The physical and service infrastructure has struggled to keep pace. Potable water access and access to water sealed toilets remain big issues, as is food security. urban HEART helped the city identify the four arrondissement that required greater activity, in particular around the provision of health services and prevention activities.
Plenary discussion: Next steps
One issue that was raised is whether there a need or mechanism to involve state and national governments in Urban HEART? Though this approach would have relevance to them, a big part of the appeal of Urban HEART is the clarity of the indicators and its applicability at the city level.
The distinction between Urban HEART as an indicator/diagnostic tool and a framework to guide implementation came up a few times. It’s intended to be both, but there’s a tension, which most HIA practitioners would have encountered as well.
There was quite wide-ranging and detailed discussion about approaches to building capacity for Urban HEART, which I won’t describe in detail here because I’m not able to do justice to the range of issues discussed. Some of the broad topics touched on included:
sharing best practice, particularly in the form of brief case studies focused on key learning
building Urban HEART into WHO and country-level work plans
linking to professional groups/associations
ensuring the health sector comes along the journey and that Urban HEART doesn’t become the sole responsibility of cities/other sectors
how often does Urban HEART need to be revisited/redone
how can we make Urban HEART sell itself, i.e. so it doesn’t need much ongoing support
compendiums of best practice and then thinking how some of these best practice cases might be synthesised
how to advance an equity agenda in settings where it’s not on the political agenda
These issues are all eerily familiar to people who’ve worked on HIA! It was an excellent Consultation with lots of food for thought that also highlighted how well-designed Urban HEART is and how much work has gone into its development. I plan to do another post in a few days that brings together some of the critical points and what the implications might be for HIA.
I’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 2 of the Consultation, there are also posts on Day 1 and Day 3.
Workshop 1: Review of Urban HEART concepts
The first workshop focused on factors affecting health equity that might be missing from or not sufficiently emphasised in Urban HEART. These include things like gender, food and nutrition, emergency preparedness, conflict and security, universal health coverage and environmental sustainability.
The issue of within-neighbourhood disaggregation was discussed, particularly in terms of age and gender, but there was a broad recognition that this data simply isn’t available for most indicators and that this may add a layer complexity to an already imposing process. There was also a recognition that many indicators of health equity might not be sensitive enough, or may reflect structural or systemic inequalities, to change at the local or city level. These issues will be very familiar to those who have looked at equity and vulnerability within impact assessments.
There was quite a bit of discussion about the degree to which Urban HEART needs to be regarded as a standardised, readily-comprehensible approach or something that can be adapted to local needs. This is a debate I’ve encountered several times in relation to HIA and the answer seems to lie somewhere between those two extremes.
City case presentations
A presentation from Dr Oyelaran-Oyeyinka from UN-HABITAT emphasised the important role cities play as the engine rooms of economic development, though the challenge is to ensure that’s inclusive development. Internationally the urban-rural divide is diminishing but the rich-poor divide is increasing.
Kelly Murphy from St Michael’s Hospital in Toronto presented on her work adapting Urban HEART for use in developed countries. The City of Toronto has adopted Urban HEART as a mechanism to guide funding of Neighbourhood Improvement Areas and Issue to 2020.
The difficulties encountered in Toronto include:
working together (team changes, maintaining relationships, timelines, expectations)
Urban HEART being easy to use but not easy to produce (the process is clear but the sources of data is not, potential misinterpretation of results, e.g. stigmatising areas or only focusing in “red” areas when gains could be made in “yellow” ones).
The facilitating factors in Toronto incude:
WHO Brand associated with Urban HEART lent it credibility
credible technical expertise (epidemiologist with recognised track record and relationships)
senior champions (administrative rather than elected representatives)
City’s willingness to innovate
lead partner providing secretariat support (so the process “belonged” to someone)
specific funding from CIHR to get the ball rolling, though the City of Toronto has now adopted this as a process within its “Wellbeing Toronto” monitoring and reporting activities
Kelly spoke about the need to talk about equity for all sectors, as opposed to health equity, and responsiveness to policy processes. Urban HEART was regarded as a clear tool that “made sense”. Despite being a developed city, Toronto found that Urban HEART was a useful approach and that the domains of the tool were still relevant.
Jose Velandia Rodriguez from Bogota, Columbia also spoke about his experience using Urban HEART in Bosa, a region within Bogota.
Workshop 2: Review of Urban HEART indicators
Most cities that have used Urban HEART have had to adapt the core indicators to some extent, or only use some of them. Most cities have also used secondary or suggested indicators as well, rather than solely the core indicators. The evaluations of city case studies so far have emphasised the need to integrate environmental and qualitative indicators/information to a greater extent.
There was a wide-ranging discussion of how and whether universal health coverage should be reflected in the Urban HEART indicators. There was a broad agreement that there should be at least one amongst the core indicator set that deals with universal health coverage, given the global focus on it, but it’s hard to identify what the key domains of UHC are. It’s generally regarded as having three dimensions – access to health services, utilisation of health services and financing of health services. There was recognition across the workshops that whilst UHC financing clearly has an impact, it often lies beyond the scope of local government to influence. They have a greater role in access and utilisation, often by providing co-funding or premises and in some cases payments to cover the direct health care costs of the poor.
The discussion on this was wide-ranging and quiet comprehensive. Rather than recapping it here I’ll just note that WHO is currently developing a UHC indicator set, which will be drawn on in selecting the UHC indicators to be included in Urban HEART. The indicators will need to focus on access and quality and have some sensitivity to vulnerability and equity at the local level. In general, geographic distribution of services is an available indicator in many settings, but beyond that it’s hard to say what will be available. Health care-related impoverishment (where people are pushed into greater poverty by healthcare costs) and catastrophic health expenditure were identified as important measures with clear equity implications, though it is unclear about how these can be turned into indicators reliably or meaningfully.
There was also discussion about how to incorporate ageing-related indicators into Urban Heart, though the consensus was that it may be more important to ensure there is disaggregation of other indicators by age rather than adding new indicators. It may be useful to refer people to WHO’s guidance on age-friendly cities where appropriate.
Emergency management indicators have already been committed to in some form, following WHO discussions with other UN agencies. These might include existence of emergency standard operating procedure plans in local government agencies. Other indicators might include prevalence of disaster-resistant buildings, e.g. earthquake-resistant buildings, people trained in emergency response, presence of local emergency response groups/networks, etc.
Qualitative data may help to fill in gaps and supplement other indicators. There was some discussion about how to integrate and present qualitative data in Urban HEART.
A bigger issue is that there is a need to ensure Urban HEART has as few possible indicators as possible in order to enhance usability, and that the indicators included are all equity-sensitive and available. They also essentially need to be geo-coded, at least at a neighbourhood level, and very few indicators are in *any* setting. Addressing this will be no easy task.