Equity Audit: non-health interventions

1. Equity Audit: non-health interventions Sarah Simpson EquiACT Conjoint Lecturer, UNSW Erice, Italy 14 April 2012

2. Health equity audit – UK model Source:Goodrich & Pottle, 2005

3. Health impact assessment Screening Scoping Identification of impacts & collection of data Assessment Final report and recommendations Monitoring and evaluation

4. HEA and HIA: related & slightly different Health Equity Audit Health Impact Assessment Screening Scoping Identification of impacts & collection of data Assessment Final report and recommendations Monitoring and evaluation • Agree partners and issues • Equity profile – identify the gap • Agree high impact action to narrow the gap • Agree priorities for action • Secure changes in investment and service delivery • Review progress and assess impact

5. Health Lens Analysis: South Australia Engage - establishing and maintaining strong collaborative relationships with other sectors. Gather evidence - establishing impacts between health and the policy area under focus, and identifying evidence-based solutions or policy options. Generate - producing a set of policy recommendations and a final report. Navigate - helping to steer the recommendations through the decision-making process. Evaluate - determining the effectiveness of the HLA. Source: Wiliams, 2010.

6. Critical issues What is the issue & why is it important? Scoping the assessment • What is the relationship between the determinant and health & inequalities: mapping pathways – conceptual framework. • What data to collect & how? • Defining “success” A systematic process for analysis of the knowledge/data collected Making recommendations Making the case for uptake

7. Non-health interventions: scope – Italian context • Interior • Justice • Labor and Social Provision • Public Education • Infrastructure and Transport • Customs and excise • Treasury • National Statistical Institute • Agriculture and Forestry • Communications • Cultural Assets and Activities • Defence • Foreign Affairs

8. 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?

9. Non-health interventions: why HEA? What is the incentive/motivation for HEA? Health sector is at the core of the exercise – health sector interest? Win-win or mutual interest? What health can do for other sectors? Damage limitation in relation to negative health impacts?

10. First step of Health Lens Analysis: engage Source: Wiliams, 2010.

11. 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)

12. 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)

13. 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)

14. 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?

15. From employment to health?

16. From employment to health inequalities?

17. Connecting employment & health inequalities Quality of employment & distribution of health outcomes SDH Source: EMCONET Final report, 2007; p.31

18. Definitions – employment issues 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 Employment conditions – 5 dimensions – unemployment, precarious employment, informal employment & informal jobs, child labour, and slavery/bonded labour Working conditions - tasks performed by the workers, way work is organised, physical & psychosocial work environment & technology used Source: EMCONET Final report, 2007.

19. 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). (IMF. Italy. Selected Issues. 2012; pp.11-13)

20. 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)

21. Introducing an equity lens

22. Erice – equity lens

23. Equity lens – priority public health conditions Source:Equity, Social Determinants and public health programmes. Blas E, Sivasanakurup A (eds). Geneva, WHO, 2010

24. 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

25. 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 ..

26. “Vulnerable groups” and equity Age & life stage Socioeconomic & other Level of education Level of income Ethnicity e.g. Roma Citizenship status Place of residence …. • Pre-natal • Babies/infants • Young children • Adolescents • Pregnant women • Older people Physiological & biological Socially determined

27. Equity: concept of “success” Reducing inequalities – what does this look like Not making existing inequalities worse Remedying health disadvantage Closing the gap Tackling the social gradient

28. Tackling inequalities: what does it look like? Source: Asquith et al,, 2011; p.39

29. Employment & equity: “decent work” Freedom from coercion Job security – contracts & safe employment conditions Fair income – to guarantee adequate livelihood to the needs of society Job protection & availability of social benefits Respect & dignity at work Workplace participation Enrichment & lack of alienation Source:ILO in EMCONET Final report, 2007

30. Employment conditions – health & inequalities Source: EMCONET Final report, 2007; p.32

31. Worked example: labor market in Italy Employment conditions Working conditions What are the exposures and risk factors for these groups? Physical – injuries Chemicals & other exposures Ergonomic Mental & psychosocial Who is: • In full employment? • Unemployed • Precariously employed • In informal employment • Child labor ? • Slavery & bonded labor?

32. Where to for the data?

33. 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

34. 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

35. 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

36. 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”?

37. 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

38. Great expectations? Equity audit report is done – what is the expected outcome? Outcomes can be varied • Better information for evidence-informed 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?

39. “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

40. 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!

41. THANK YOU

42. References 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/health-inequalities-commissioning-framework- Employment Conditions Knowledge Network (EMCONET). Final Report, 20 September 2007. Available from http://www.who.int/social_determinants/resources/articles/emconet_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-13-03.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 E, Sivasanakurup A (eds). Geneva, WHO, 2010 Williams C. South Australia’s Health in All Policies Approach. Adelaide; 2010.

43. 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_determinants/themes/en/