Wiput PhoolcharoenI; Decharut SukkumnoedII,1; Puttapong KessomboonIII
IDirector, Health Systems Research Institute, The 3rd Building Department of Mental Health, Ministry of Public Health, Nonthaburi, Thailand
IILecturer, Faculty of Economics, Kasetsart University, Phaholyothin Road, Chatuchak, Bangkok 10900, Thailand (email: email@example.com)
IIIAssistant Professor, Faculty of Medicine, Khon Kaen University, Thailand
The development of health impact assessment (HIA) in Thailand is taking place in difficult circumstances but with high hopes. For many years, the government has taken a clear direction to change Thai economy and society into a newly industrialized country. Many policies designed to fulfil this strategy, however including investment in infrastructure and industrial development have caused negative health effects on local people. Without a process for proper public participation, many conflicts have arisen around almost all large government projects throughout the country.
The constitution established in 1997 provided an enormous opportunity for further progress in restructuring the relationship between the state and civil society. It stimulates the process of decentralization of decision-making and resource allocation, and has created new institutions and mechanisms that allow greater accountability, transparency, representation, and participation at all levels of the development process. It calls for urgent empowerment of citizens, in order to facilitate their influence on the decision-making process in all aspects of implementation of the policy by both central and local government.
National health system reform, launched in 2000, has initiated the new concept of civil involvement in public policy processes. It advocates the development of healthy public policy (or putting health into non-health sectors) to pursue the principle of "all for health" in order to achieve the ultimate goal of health for all. The novel mechanism of HIA has to be created to mediate between all stakeholders of any public policy, so that they work together for a healthier society based on sound evidence.
National Health Act
Reform of the national health system was conducted alongside the drafting process of the National Health Act, which can be seen as an essential means to mobilize all stakeholders to collaborate with each other in redesigning a new mind set for their health system. Although the Act has not yet been finalized, the draft depicts vividly the core and essential structure of the desired health system. Health is stated as the ultimate goal of development and the dignity and basic human rights of all people, and has been redefined as "a state of well-being in four aspects: physical, mental, social, and spiritual". The rights and responsibilities of individuals, the community, local government, and central government in promoting and protecting health are well established. All determinants of health equality and security have been defined in categories such as food security, economic security, social security, political security, and health care security.
The new governance structure in the health sector has been introduced with two main new institutions: the National Health Assembly, as a forum for discussion where people may express their views and aspirations regarding health, and the National Health Committee, as the coordinating body to provide recommendations on national health policy and strategy. The concept of healthy public policy has been developed to ensure that any public policy will take health into account. At the same time, development of the HIA process is an important tool for participatory learning for healthy public policy-making.
The drafting of the National Health Act is planned to finish in 2003, after which it will be submitted to the parliamentary process. Presently, public awareness raising and political involvement schemes are progressing hand in hand with knowledge development in these essential elements of the National Health Act.
HIA development: platforms and pillars
One of the most important aspects to be developed in support of Thailand's health system reform is the knowledge base. The Health Systems Research Institute (HSRI) launched an HIA research and development programme to support the reform in 2001. Its first step was the review of HIA experiences in some selected countries, from which HSRI identified two basic platforms of HIA development that are very important for Thailand to consider.
First, HIA can be developed as an additional part of the Environmental Impact Assessment (EIA) process, by focusing more on health as a holistic approach. This approach implies that HIA becomes an approval mechanism under the umbrella of the EIA process, which can be seen in Canada and New Zealand. The scope of HIA application is mainly concentrated at project level.
A second manner in which HIA can be developed is as an essential tool for influencing healthy public policy; this is seen in the Netherlands and the United Kingdom, both of which aim to use HIA to tackle inequalities in health. HIA in this platform is recognized as a participatory learning process rather than an approval mechanism. It does not provide the answers but, rather, provides recommendations to decision-makers, supported by strong evidence.
At first, many researchers and local communities in Thailand tended to focus on the first platform, since it provides the authority for accepting or rejecting a project proposal. However, the practical weaknesses of this approach in Thai contexts have been pointed out. To implement HIA with a broader scope of participation, the existing EIA process would need to be changed, which is not easy to achieve politically: such a proposal might encounter strong political opposition against the whole movement of health system reform. With inadequate knowledge, experience, and human resources, HIA is highly exposed to political abuses of its process if it becomes a formal project approval mechanism.
After lengthy discussions, in August 2002 the National Health System Reform Committee decided to use the second platform of HIA development to cover broader ranges of the public policy process, both in terms of level and area. It will also support political acceptance of the whole concept of national health system reform, as well as allow the development of a critical mass of HIA knowledge.
According to international review, discussion, and recent experiences in Thailand, HSRI has concluded that the effectiveness of an HIA process depends on the development of four pillars: appropriate analytical frameworks for a continuously participatory learning process have to be demonstrated; an effective institutional structure has to be designed to facilitate HIA implementation and to influence HIA process, impacts, and outcomes in public policy-making; a critical mass of well-understood technical experts and activists needs to be formed to support the satisfactory performance of the other pillars; and an enabling environment must be established for the learning process, fostering constructive dialogue and advocating healthy public policy. The creation of an enabling environment is essential and includes different activities that facilitate public communication on healthy public policy issues, such as newsletters, web sites, broadcasts, and local and international forums.
The development of an appropriate analytical and institutional framework is the key challenge for successful HIA implementation. Such a framework needs to provide knowledge to all stakeholders and to inspire their trust, so the HIA implementation can be carried out only through a deliberate learning and participatory process. However, because of limitations in the Thai context, developing such a process is complicated and lengthy.
The primary limitation stems from incomplete knowledge and information on both environmental and health issues, especially their social and spiritual health aspects. Further restraints are the limited time and resources available for the HIA process, and other problems arise from the vast differences in capacity for information and technical access between different stakeholders in the impact assessment process. Lastly, all these inequalities lead to both social exclusion and mistrust in the decision-making process.
To cope with these difficulties, it is suggested that the HIA process in Thailand has to be developed with five main considerations in mind.
Methodologies and tools have to fit with the available information, knowledge, resources and time lines.
Development and collection of the existing and new methodologies and tools are essential to build a bridge between academic knowledge and local empowerment.
Frameworks and approaches for assessing the social and spiritual health impacts in the local context are required, with possibly a little help from international experiences.
HIA analytical frameworks have to be flexible enough to apply to different types of public health, environmental, social, and economic policy.
Mapping of the public (or political) decision-making process has to be worked out and taken into account in advance; this will help HIA facilitators and researchers to: (a) identify the policy problems; (b) communicate with healthy public policy partners; (c) develop appropriate policy proposals; and (d) search for policy windows in the political processes.
The calendar of events in the development of HIA in Thailand is summarized in Table 1. To facilitate HIA development, HSRI has organized three forms of related implementation bodies. First, an HIA coordination team was set up to bring together all HIA actions, as well as to develop new knowledge, information, and learning activities. Secondly, three HIA regional networks were established to support the learning process and the accumulation of a critical mass of knowledge in the regions. Lastly, five HIA thematic networks have been developed with the clear objective of creating a bridge between sound evidence and public policy formulation in different policy sectors.
At present, about 20 HIA case studies have been conducted in Thailand. The first version of HIA guidelines was introduced at the National Health Assembly in August 2001 and accepted as one of the core elements of the National Health Act. To create the critical mass, HIA training courses have been based on participatory learning techniques, such as role-playing and simulation, tailored to different situations and target groups. Examples of case studies and training courses are shown in Table 2.
The concepts of healthy public policy and HIA are highly relevant to the health problems and risks in Thailand and to the needs of Thai society, especially civil society. The integration of different perspectives of HIA as well as the integration of scientific and local evidence still need further development, both in individual HIA case studies and in general HIA guidelines and training courses.
One of most important obstacles to HIA development is incomplete and dispersed information on health status and environment indicators. Investment in databases and information systems becomes a priority for HSRI in 2003, to reduce the costs and time needed for HIA implementation.
Another critical point of HIA development in Thailand is the effectiveness of influence in public policy processes. HSRI plans to develop its courses on conceptual framework and training courses for "healthy public policy advocacy" this year. The establishment of new governance structures under health system reform, designed to be a policy arena for the healthy public policy process, is highly important for the effectiveness of HIA as a policy instrument. Therefore, coordination between the development of HIA and new governance structures is absolutely crucial.
At this moment, Thai society has redefined health and the health system, a redefinition that leads to the capability to envisage a holistic scope for the health system. The process of drafting the National Health Act is the first step in a long, on-going reform, which initiated the use of sound knowledge to arm public policy towards health concerns. Thus, a learning society inspired with an aim for healthy environment and peaceful society is, in itself, a means and an end for health system reform.
The key point of successful HIA development is the involvement of all stakeholders from the initiation process. Even though HSRI has identified the government sectors as the main users of the HIA process, the academic community and civil society have been recognized as firm ground on which to drive healthy public policy. However, the transformation of technical knowledge into system changes has only been legitimized with the endorsement of both civil society and the government. This might be the first time in Thailand's history of public policy that academicians have been enlisted to work side by side with political powers and civil society.
Conflicts of interest: none declared.
1 Correspondence should be addressed to this author.