Equity Audit: non-health
interventions
Erice, Italy
14 April 2012
Sarah Simpson
EquiACT
Conjoint Lecturer, UNSW
Health equity audit – UK
model
Source: Goodrich & Pottle, 2005
Health impact assessment
1. Screening
2. Scoping
3. Identification of impacts &
collection of data
4. Assessment
5. Final report and recommendations
6. Monitoring and evaluation
HEA and HIA: related & slightly
different
Health Equity Audit
1. Agree partners and issues
2. Equity profile – identify the
gap
3. Agree high impact action to
narrow the gap
4. Agree priorities for action
5. Secure changes in
investment and service
delivery
6. Review progress and
assess impact
Health Impact Assessment
1.
2.
3.
4.
5.
6.
Screening
Scoping
Identification of impacts &
collection of data
Assessment
Final report and
recommendations
Monitoring and evaluation
Health Lens Analysis: South
Australia
1. Engage - establishing and maintaining
strong collaborative relationships with
other sectors.
2. Gather evidence - establishing impacts
between health and the policy area under
focus, and identifying evidence-based
solutions or policy options.
3. Generate - producing a set of policy
recommendations and a final report.
4. Navigate - helping to steer the
recommendations through the decisionSource: Wiliams, 2010.
making process.
5. Evaluate - determining the effectiveness
Critical issues
1. What is the issue & why is it
important?
2. Scoping the assessment
– What is the relationship between the
determinant and health &
inequalities: mapping pathways –
conceptual framework.
– What data to collect & how?
– Defining “success”
3. A systematic process for analysis
of the knowledge/data collected
4. Making recommendations
5. Making the case for uptake
Non-health interventions: scope –
Italian context
• Treasury
• National Statistical
Institute
• Agriculture and Forestry
• Communications
• Cultural Assets and
Activities
• Defence
• Foreign Affairs
• Interior
• Justice
• Labor and Social
Provision
• Public Education
• Infrastructure and
Transport
• Customs and excise
Non-health interventions: why
equity audit?
• What is the issue?
Improved health of workers, improved
employment conditions, better
productivity for employers …?
• Who is interested?
Health or the other sectors
Who’s driving the discussion and asking
for an equity audit?
What’s in it for other sectors? Mutual
benefit?
• What is at stake?
Non-health interventions: why HEA?
What is the incentive/motivation for
HEA?
1. Health sector is at the core of the
exercise – health sector interest?
2. Win-win or mutual interest?
3. What health can do for other
sectors?
4. Damage limitation in relation to
negative health impacts?
First step of Health Lens
Analysis: engage
Source: Wiliams, 2010.
Engaging in a Health Lens Analysis
•
•
•
•
•
•
Develop the relationship
Identify/clarify contextual issues
Negotiate and agree on policy focus
Form team and identify resources
Plan work and determine process
Establish evaluation criteria
(Source: Government of South Australia, 2010)
Worked example: labor market
reform in Italy
Labor market reform should aim to
lower labor adjustments costs,
introduce more flexibility at the
core, increase participation,
especially among women, and improve
activation policies.
(Source: IMF, 2012; p.5)
Labor market reform in Italy
April 2012 draft law sought to :
• Tackle job insecurity & dualism
• Make employment protection &
unemployment insurance more even to
Encourage more stable employment
relationships
Lower firing costs
Increase employment & participation,
especially of youth
• Strengthen active labor market
policies
(Source: IMF., 2012; p.11)
Non-health interventions: scoping
the audit
• What is the relationship between
the social determinant and health
and equity?
• Is there much evidence/data? And of
what?
at the aggregate level?
or beyond this
who collects and who owns the data
who is doing work on these issues e.g.
which academics and institutions?
From employment to health?
From employment to health
inequalities?
Connecting employment & health
inequalities
Quality
of
employmen
t &
distribut
ion of
health
outcomes
Source: EMCONET Final report, 2007; p.31
Definitions – employment issues
1. Employment relations – relationship
between an employer that hires
workers and an employee who
contributes labour, usually in return
for payment or wages - Power
relations & level of social
protection
2. Employment conditions – 5 dimensions
– unemployment, precarious
employment, informal employment &
informal jobs, child labour, and
slavery/bonded
Source:labour
EMCONET Final report, 2007.
3. Working conditions - tasks performed
by the workers, way work is
Worked example - labor market
reform in Italy: the issues (1)
• For a 15–24 year-old, the chance of
being in education is about 60
percent and being employed is
slightly over 20 percent compared
to over 35 percent in the euro
area.
• For a 40–64 year-old, the chance of
being employed is only 60 percent
(mainly driven by low female
employment) and being inactive
about 35 percent (almost 50 percent
if a woman).
Worked example - labor market
reform in Italy: the issues (2)
• If employed, a 15–24 year-old would
have a 50 percent chance that the
contract would be open-ended, while
for a 40–64 year-old this chance
would be over 90 percent.
• The transition probability from
unemployed to inactive is higher
than in other countries, especially
for women and in the South (Istat,
2011) while inactivity tends to be
almost permanent.
(IMF.
Italy. Selected Issues. 2012; pp.11-13)
Introducing an equity lens
Erice – equity lens
Equity lens – priority public
health conditions
Source: Equity, Social Determinants and public health programmes. Blas E, Sivasanakurup A (eds). Geneva, WHO, 2010
Employment and health inequalities
• In links between employment and
health – who gains?
• Do all groups have the same level
of health improvement?
• Are some groups in the population
doing better than others?
Type of work – office workers, manual laborers,
sex workers
Formal or informal sector
Men compared to women
Younger people compared to older people
Low education/lower qualifications
Employment and health inequalities
in
Italy
• Who gains?
• Do all groups have the same level
of health improvement?
• Are some groups in the population
doing better than others?
Type of work –office workers, manual laborers,
sex workers ….
Formal or informal sector
Men compared to women
Younger people compared to older people
Low education/lower qualifications
Roma, migrants ..
“Vulnerable groups” and equity
Age & life stage
•
•
•
•
•
•
Pre-natal
Babies/infants
Young children
Adolescents
Pregnant women
Older people
Physiological & biological
Socioeconomic & other
•
•
•
•
•
Level of education
Level of income
Ethnicity e.g. Roma
Citizenship status
Place of residence ….
Socially determined
Equity: concept of “success”
Reducing inequalities – what does
this look like
1. Not making existing inequalities
worse
2. Remedying health disadvantage
3. Closing the gap
4. Tackling the social gradient
Tackling inequalities: what does
it look like?
Source: Asquith et al,, 2011 ; p.39
Employment & equity: “decent work”
1. Freedom from coercion
2. Job security – contracts & safe
employment conditions
3. Fair income – to guarantee
adequate livelihood to the needs
of society
4. Job protection & availability of
social benefits
5. Respect & dignity at work
6. Workplace participation
Source: ILO in EMCONET Final report, 2007
7. Enrichment & lack of alienation
Employment conditions – health &
inequalities
Source: EMCONET Final report, 2007; p.32
Worked example: labor market in
Italy
Employment conditions
•
•
•
•
•
•
Who is:
In full employment?
Unemployed
Precariously employed
In informal employment
Child labor ?
Slavery & bonded labor?
Working conditions
What are the exposures and
risk factors for these
groups?
• Physical – injuries
• Chemicals & other
exposures
• Ergonomic
• Mental & psychosocial
Where to for the data?
Where to for the existing
available data
• Key ministries/departments and
government agencies for the
statistics e.g. National Statistics
agency, education, employment,
finance/treasury etc
• Specialist agencies within Italy
e.g. CGL
• International agencies e.g. OECD,
ILO, IOM
Where to for the data: beyond
numbers
• But what of informal workers
(particularly working in
industry/manual jobs and or
undocumented migrants)
Do they appear in the formal numbers?
Do the numbers reflect their reality?
How to get beyond the numbers?
In all cases – there is a need to go
beyond the numbers in order to develop
a comprehensive equity profile to
inform policy responses – qualitative
research or knowledge collection
Beyond the numbers: options
• Surveys through NGOs or advocacy
groups dealing with these issues
• Focus group interviews conducted by
peer mediators with those working
in the informal economy – e.g.
undocumented migrants
• Stakeholder interviews with key
academics, NGOs and advocacy
organizations
Worked example: continued
Engagement & scoping - in Italy
• What are the key policy issues in
relation to employment conditions
and health inequalities?
• Who are the stakeholders? Which
agencies – government, academic,
NGOs & civil society?
• Which government agency is or needs
to be leading the process to ensure
uptake of these issues?
• What will be counted as “evidence”?
Purpose of an equity audit
• Purpose of an equity audit is to
develop knowledge about potential
health equity impacts to inform
decision making – for planning, for
implementation, for monitoring ….
depending on the cycle of the
policy/intervention process
Great expectations?
• Equity audit report is done – what
is the expected outcome?
• Outcomes can be varied
Better information for evidenceinformed implementation and or
monitoring
Uptake of some or all of the
recommendations into the policy, or
planning processes
A report that sits on the shelf as
evidence of potential impacts?
“Making the case”
• Think about framing of the messages
– who is your audience
• Language
• Engagement
• Context
• Prioritising recommendations and
health equity impacts – not an
infinite list
• Solution oriented – improvement and
amelioration not resistance/impasse
– positive policy and intervention
development
Take home messages
• Equity audit reflects similar steps to
other assessment processes e.g. HIA,
planning, health lens analysis
• Action on social determinants of health
is not the same thing as action on
inequalities
• Vulnerability - interaction between
physiological and socioeconomic
• Getting the engagement and scoping right
• Agreed conceptual mapping
• Going beyond the numbers
• Making the case for uptake – moving the
audit off the desk!
THANK YOU
References
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Asquith H, Shaffelburg S, Adepoju A, Griffiths P. Health
inequalities commissioning framework. NHS Kensington and
Chelsea, January 2011. Available from
http://www.instituteofhealthequity.org/projects/healthinequalities-commissioning-frameworkEmployment Conditions Knowledge Network (EMCONET). Final
Report, 20 September 2007. Available from
http://www.who.int/social_determinants/resources/articles/emcon
et_who_report.pdf
Goodrich J, Pottle M. Making the case: health equity audit
[Internet]. NHS Health Development Agency; 2005 [cited 2013 Jan
29]. Available from:
http://www.nice.org.uk/nicemedia/docs/Making%20the%20case-1303.pdf
Government of South Australia, SA Health. Health in All
Policies: The South Australian Approach. Government of South
Australia; 2010.
International Monetary Fund. Italy. Selected Issues [Internet].
Washington D.C: International Monetary Fund; 2012 Jul. Report
No.: 12/168. Available from:
http://www.imf.org/external/pubs/ft/scr/2012/cr12168.pdf
Equity, Social Determinants and public health programmes. Blas
Useful sites/resources
• EMCONET - http://www.emconet.org
• HIA gateway http://www.apho.org.uk/default.aspx
?QN=P_HIA
• OECD - http://stats.oecd.org and
http://www.oecd.org/employment/emp/
onlineoecdemploymentdatabase.htm
• ILO http://www.ilo.org/global/lang-en/index.htm
• WHO http://www.who.int/social_determina