Ruth Barnes, Independent Public Health Consultant

What is Public Health?

  • The health of the population as a whole, especially as the subject of government regulation and support.

In one way or another I have been involved in HIA for over six years now and, for rather longer, I have been describing, trying to explain and endeavouring to address the issue of inequalities in health. Yet is only through my work in HIA that one very important question has crystallised in my mind: “inequalities between whom”

Female doctor with the stethoscope holding heart

All my HIA (and other) work has a strong focus on inequalities and equity issues, not only because it plays an important part in my personal ideology but also because it is an underpinning principle in HIA (and it may, of course, be one of the reasons I was attracted to HIA as a new approach to the evaluation of public policy when the political climate appeared to change following the general election of 1997)An equity focus has been almost inevitable in all my pieces of HIA work because they have, on the whole, dealt with regeneration programmes which are, by definition and by funding, geared towards “disadvantaged” areas. As a result, there is an underlying assumption that if the focus of an HIA is within a disadvantaged area – usually meaning disadvantaged in terms of poverty and deprivation indices – the issue of inequalities is automatically addressed. I would suggest that this isn’t actually the case.

Whilst there is often an explicit reference to disadvantaged groups (perhaps related to income, ethnicity, education or other related factors) the equity component in HIA is too often implicit rather than explicit. This means that some equity issues are overlooked. The challenge, I believe, is to start to find ways of making the inequalities and the equity component of HIA much more explicit.One way of doing this is to define clearly the scope of the HIA at the outset by asking the question: is it focussed on the current population or on the physical infrastructure of the area itself? I have undertaken several HIAs which have shown the importance of being clear about whether the regeneration programmes – and the HIA – is focussed on an area or a population. Some of these, for example, have been in areas where there has been an emphasis on developing education and training programmes with a view to improving people’s employment level and, therefore, raising average incomes.

If there are differential uptake rates of education masters in public health , training and careers opportunities or internships and jobs. the population remains static, inequalities within the population can be increased and social cohesion decreased. Alternatively, those who benefit most may move out of the area leaving a core of the most disadvantaged, harder to reach groups and the deprivation indices of the area over time will, at best, remain the same and, at worst, deteriorate. All this results from the incorrect assumption that if the worst off groups are targeted there will be an equal effect amongst all of them.This issue raises other important questions about the evidence base and about monitoring and evaluation if HIA is to be assessed over time in terms of its effectiveness as a process and about its accuracy as a predictive tool. I have started to look at these issues in my own work and in other commissioned studies.

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