In the impact of economic crisis on the health of populations, the direct or indirect consequences of health policies, and, above all, those of other sectors, are clear. Thus, Health Impact Assessment becomes a pressing need to monitor, predict and correct potentially serious effects for the health of the population at large and of risk groups in particular.

In 2009, Dr. Margaret Chan, Director General of WHO, stated that "the crisis would vary from country to country, but there was a growing consensus about what should be done": “to ensure quality information in real time" to inform decision making, "to identify high-risk groups, to ensure that social support programmes reach those most in need, to find efficiencies in expenditure where possible, to recognize that crises often offer opportunities for reforms, to keep spending on a prevention level, and, where external aid is necessary, to ensure that it is as effective and efficient as possible ”[1].

Nonetheless, when reading the so-called "Troika Memorandum" to be implemented from 2011 to 2013 by the new government, and the Programmes for Stability and Growth 1, 2, and 3 (PECs 1-3), already implemented by the previous government, it becomes difficult to find some of these priorities, especially with regard to social order and prevention. No doubt the seriousness of the situation in the country justifies taking drastic measures. However, the apparent complete dehumanization of the process forgets that change is made by people. As such, economics is a social science and the human factor cannot be ignored.

For example, the sheer dramatic reduction in purchasing power of the population in general may have serious impacts on the levels of health and well-being (Box1). Vulnerable groups (i.e. the elderly and the unemployed) will be further affected unless parallel preventive measures based on health impact assessment are taken (Box2).In addition, health impact assessment includes evaluating the impact of policies from other health sectors, as well as of health policies in other sectors. Negative effects on the health of populations generate adverse effects on the economy: direct costs such as increased spending on health, but also indirect costs, such as decrease in productivity.

Hence the importance of Health in All Policies (HIP-Health in all Policies), again recently defended in the Adelaide Charter, which calls for a new role for the health sector: to become a partner across all other sectors in policy making that contributes to human development, sustainability and equity [7]. We will see if the crisis does in fact represent an opportunity for reform.

BOX 1

Some non-health sectors measures with potential negative effects on health:

*Reduction of pensions above 1.500 € (minimum savings: 445 million €)
*Suspension of indexation rules and freezing of pensions, except the smallest, in 2012
*Reform of unemployment benefit (medium-term savings: 150 million €)
*Reduction of IRS benefits/tax deductions (minimum revenue: 150 million € in 2012): thresholds for smaller deductions or no deductions for higher income brackets; maximum deduction for medical expenses; end of deductions on debt charges from property acquisitions.
*Increased revenue from VAT and special excise duties on consumption (vehicles, tobacco, electricity)
*Civil Servants: Freezing of nominal salaries 2012-2013.BOX 2

The tools and methodologies for health assessment have been identified in four complementary areas [2]:

• Health Impact Assessment: it allows measuring, predicting and monitoring impacts on the health of specific populations (and corresponding distribution) of any project/policy in any activity sector [3], with a view to assisting decision making, analyzing the implications of the health project or policy and advancing measures that minimize negative impacts and maximize positive ones.

• Equity Focused Health Impact Assessment: Even more than the HIA, it focuses on identifying potential inequalities affecting the populations covered by the project/policy and searches for solutions that promote equity [4].

• Health Systems Impact Assessment: It is used mostly in a context of integrated assessment of policies on health systems, incorporating economic, social and environmental impacts [5].

• Health impact assessment in other areas: it falls basically within a context of health economics in the analysis of the effects of health investment on the economy, development and well-being of society. Investing in health has direct and indirect effects, via health systems, the GDP of a country, affecting the competitiveness of the economy as a whole, such as, for instance, effects on labour costs, flexibility of the labour market, and the allocation of resources at a macroeconomic level. [6]. This area is particularly important in engaging non-health sectors in investing in HIA, as it quantifies potential return in other areas of health investment.

Leonor B. Nicolau
Lecturer at the Institute of Preventive Medicine
Faculty of Medicine of the University of Lisbon
leonor.bnicolau@netcabo.pt

_________________
References

1. Chan, M. Impact of financial crisis on health: a truly global solution is needed - Statement by WHO Director-General, Dr Margaret Chan;1 April 2009
2. Bacelar-Nicolau, L.B., “Estudos de Impacte sobre a Saúde: Quantificar e Modelizar uma Realidade Multivariada”, Tese de Doutoramento -co-tutela FM-UL, Portugal/Conservatoire National des Arts et Métiers, França; 2008 (em curso)
3. Heitor MJ, Pereira Miguel J. Avaliação do Impacte de políticas de diferentes sectores na saúde e nos sistemas de saúde: um ponto de situação. Revista Portuguesa de Saúde Pública; 2009 January 1;27(1):5-17.
4. Simpson S, Mahoney M, Harris E, Aldrich R, Stewart-Williams J. Equity-focused health impact assessment: A tool to assist policy makers in addressing health inequalities. Environmental Impact Assessment Review; 2005 October;25(7-8):772-82.
5. Deltour, A., Hedin, A., Koho, A., van Elk, B., Lathinen, E., Liaudanskiené, R., and Pereira Miguel, J. Working Group on Health Impact Assessment and Health Systems: Towards Health Systems Impact Assessment. High Level Group on Health Services and Medical Care;2004.
6. Suhrcke M, Mckee M, Sauto-Arce R, Tsolova S, Mortensen J. The contribution of health to the economy in the European Union. Health&Consumer Protection Directorate-General - European Commission - European Communities;2005.
7. Adelaide statement on health in all policies: moving towards a shared governance for health and well-being. World Health Organization. Health in All Policies, Adelaide 2010, Adelaide, South Australia,13–15 April.