Crossing Bridges Developing methodologies and building capacity to advance the implementation

of HiAP and achieve health equity

Minutes - Kick Off meeting 3-4 March 2011

Participants: Sara Bensaude de Castro (IUHPE), Bruno Buytaert (Belgium), Justyna Car (Poland), Caroline

Costongs (EuroHealthNet), Noelle Cotter (Ireland), Mojca Gabrijelčič Blenkuš (Slovenia), Hana Janatova

(Czech Republic), Yoline Kuipers (EuroHealthNet), Athena Linos (Greece), Claudia Marinetti

(EuroHealthNet), Owen Metcalfe (Ireland), Sabrina Montante (Italy), Clive Needle (EuroHealthNet),

Daniela Negri (Italy), Sharon Rawlinson (UK), Helene Reemann (Germany), David Ritchie (UK), Roisin

Rooney (EAHC), Marielle Schipperen (Netherlands), Ingrid Stegeman (EuroHealthNet), Veerle Stevens

(Belgium), Agnes Taller (Hungary), Nicoline Tamsma (Netherlands), Malcolm Ward (Wales), Caren

Wiegand (Germany), Charlotte Wirl (Austria), Dina Zota (Greece).

Apologies: representatives of all associated partners were present.

Power point presentations made during the meeting will be made available on www.health-

inequalities.eu under Events/Past Events. Please note that the website currently has a DETERMINE

branding, but it will undergo reconstruction and a new website, incorporating Crossing Bridges

information, will be established by June 2011.

Day 1

Chair: Clive Needle, director EuroHealthNet

13:00 – 14:00 ∙ Session 1: Setting the Scene. HIAP, where are we?

Opening and introduction by EuroHealthNet

Clive Needle, Director of EuroHealthNet, opened the meeting and welcomed the Participants. He

emphasised that, despite the short duration of the project (18 months), the Crossing Bridges project will

hopefully not only produce valuable outcomes in terms of encouraging and facilitating the

implementation of HiAP, but also enrich the network of people involved or interested in addressing

Health Inequalities (HI) through this approach. He hoped the project would provide the ‘bullets’ needed

to persuade other policy areas to engage more with health.

Introduction Round

Participants introduced themselves and expressed their wishes in terms of project outcomes. A number

of participants indicated that they were happy that the project enabled them to build on the work of

previous EC co-funded projects in this area, and to continue the process of learning from one another.

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Many expressed the hope that the project would lead to practical, concrete and applicable approaches

to implementing HIAP, and that it would make this approach more visible in their countries.

Setting the Scene

Three external speakers provided presentations on the ‘State of the Art’ in the area of HIAP:

François Decaillet, Senior Policy Advisor from the WHO Regional Office for Europe, provided an

overview of what WHO Europe is doing to address HIAP. He stated that we need to move from the

question of “what” to the question of “how”, when addressing HiAP approaches; we need to speed up

implementation of statements and findings, through concrete, tangible activities. He also noted that it

is important to have health and equity in all policies, not only health.

Mr. Decaillet also highlighted two important events that have put the HiAP discussion on their agenda:

the next Ministers forum (October 2011), which will discuss HiAP as one of their main themes, and the

Global Conference on Health Promotion in Finland that will focus on HiAP and Health Equity. He also

mentioned two reports that have been commissioned by WHO Europe that will feed into its Health2020

Strategy, which is in the process of being developed and aims to provide an integrated and consistent

framework to address recent challenges to health and health equity in Europe. The first is Professor Sir

Michael Marmot’s Review on the Health Divide in Europe, and the second a report on health

governance, relating to HIAP, that is being coordinated by Professor Illona Kickbusch.

Mr. Decaillet stated that the most important policies in which we should put more health are those

relating to the economy. The health sector employs 10% of the workforce, and could employ even more.

In addition, investing in health can also boost the economy and help to create jobs. He noted the

importance, in this context, of thinking about what the health sector can do for social innovation.

Felix Mittermayer, Policy Analyst in the Health Strategy Unit at DG SANCO, talked about the need for

other policy areas, such as the EU agricultural policy (CAP), to take public health into account. Impact

assessments are needed, to check the potential impact of new legislation that is under development.

Commonalities between goals and policies should be found, and access to EU investment fund criteria

could keep health into account.

Mr. Mittermayer noted that whereas in the past other sectors may not have taken health into account,

there is now a change in opinion as, e.g. the agriculture and economic sectors are aware of the

importance of health. Nevertheless Mr. Mittermayer stressed that these and other sectors need a lot of

support and help from the health sector, in the form of concrete and transparent evidence, to inform

about the health outcomes of different policy measures. Officials in other policy areas cannot ignore

good evidence. A meeting participant commented that while progress has been made in CAP reforms, it

is still a very important issue, as the EU is still spending more on subsidies for tobacco producers than for

its PH programme, and fruits and vegetables are still being ‘dumped’ to keep prices up.

Roisin Rooney, from the Executive Agency for Health and Consumers, presented on the work of the

European Commission to address HI. Ms. Rooney gave an overview of the EC Communication on the

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reduction of HI (Commission Communication COM (2009)567), the EU Health Strategy (2008-2013), and

a number of initiatives and projects on HI that have been conducted or are currently running.

Measurements of HI are fundamental, and knowledge on the effectiveness of policies to tackle

inequalities needs improving. Information was also provided about the Meeting of the EU Expert Group

on Social Determinants and HI on 5-6 April 2011.

Caroline Costongs, Deputy Director of EuroHealthNet, highlighted the fact that there are other current

activities related to addressing HI that EuroHealthNet is involved in, which fit into a coherent package:

the Joint Action on Health Inequalities; a Health Inequalities Tender; the GRADIENT (FP7 Research

Project on tackling health inequalities amongst young families and children); SPREAD (FP7 Research

Project focussing on sustainable development, in which EuroHealthNet is bringing in health

considerations) and co-funding from PROGRESS (DG Employment and Social Affairs).

14:00 – 14:45 ∙ Session 2: Overview of Crossing Bridges

Project overview and planning

Ingrid Stegeman, Project Coordinator at EuroHealthNet, summarized previous findings from the

DETERMINE project and introduced the Crossing Bridges project. She noted that HiAP is not a new

concept, but that the difficulty is to move from theory to practice and that it is important to maintain

and to build on the current momentum of different initiatives in this area. Ingrid reported the main aims

of the Project, emphasizing the need for it to contribute to practical measures to advance the

implementation of HiAP in EU Member States. The main objectives are: to analyse existing practice and

to develop methodologies to implement HiAP from such analysis and to assess capacity needs and to

subsequently build the capacity of partners to take a leadership role in promoting HiAP. Ingrid also

presented an overall timeline of the project, with the milestones and deliverables (available as a

handout).

15:00 – 17:00 ∙ Session 3: Selecting Focus Groups

General work plan for Focus Area groups and expected outcomes

Ingrid Stegeman presented on Work Package 4 (WP4), giving an overview of the approach that the

Focus Area groups should follow in order to identify factors and mechanisms present in good practices

that enable collaboration between health and other policy sectors. She also presented the timeline

applicable to WP4 and pointed out that partners should, when selecting the Focus Areas, take into

account the EU priorities in terms of targets set up for 2020, their organisations needs with respect to

collaborating with other sectors, and those areas in which they could provide expertise and examples.

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HiAP approaches in the Netherlands

Nicoline Tamsma, from the National Institute for Public Health and the Environment, presented

examples of HiAP in the Netherlands. Despite the fact that there are no specific legal requirements for

HIA or HiAP at national level, a series of initiatives have been taken both at the national and local level.

Further improvement could be achieved by developing health programmes that specifically adopt a HiAP

approach. However, Nicoline pointed out that a recent change in government brought along changes in

health promotion activities. This does not mean that there won’t be a focus on health promotion, but

the priorities will change. Following the presentation, Clive Needle emphasized the importance of

thinking also about sustainability in cases where there is a change in governmental or political

leadership, with the consequent changes in policy and values.

Short introductions to possible Focus Area group topics

Three presentations were then given by potential Focus Area group leaders, setting out possible areas

that HiAP work could focus on:

Owen Metcalfe, Associate Director and Senior Management Team member of the Institute of Public

Health in Ireland, talked about actions that are being taken in Ireland in order to address HI. He noted

that beyond factors such as healthy food, good sanitation, good health care, clean environments, issues

such as justice, transport, leisure, etc are also important to health. He also mentioned a list of challenges

that his Institute has experienced when implementing an HiAP approach: lack of commitment, the fact

that implementing such an approach is not-mandatory, limited resource capacity, accountability issues,

an overload of impact assessments and the difficulty of identifying proven added value.

Owen presented to two examples of work undertaken by his Institute to provide evidence to other

sectors on health impacts, namely a Review on Active Travel and a Review on the Health Impacts of

Education. He indicated that the Institute of Public Health in Ireland would be happy to lead Focus

Groups in either area, but, when pressed to make a choice between the two, elected to focus on Active

Travel and Planning, as this was the area that they had worked in most recently. He noted that, within

the limited resources available, Focus groups must realistic regarding what they could achieve, targeted,

innovative and capture new perspectives.

Mojca Gabrijelčič Blenkuš, Head of the Health Promotion Centre of the Slovenian National Institute of

Public Health, reported on the Slovenian experience with inter-sector work between the health,

agriculture, and education sectors. She indicated that her Institute would be happy to lead a Focus

Group around the EU ‘School Fruit Scheme’ and the ‘Most Deprived People Scheme’, which all EU

Member States were being asked and receiving funds to implement, and that involved these three

sectors. Mojca stressed the importance of understanding thoughts, ideas, attitudes, and motivation of

people involved in different policy sectors (e.g. agriculture) in order to achieve a successful

implementation of HiAP.

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Malcolm Ward, Principal Health Promotion Specialist at Public Health Wales, presented on the link

between employment and health, about the costs of working age and ill-health, and about what actions

have been taken in Wales to address these unemployment-related health issues. Malcolm indicated that

addressing HiAP is difficult in the UK and other countries with different levels of government. In the case

of Wales for example, the Welsh Assembly Government develops policy relating to health and social

services, while the UK government is in charge of fiscal policy. He stated that: “health has to be in all

policies... but whose policies?”

Discussion on possible Focus Area group topics

Following these three presentations, four potential Focus Group areas were identified. Through a show

of hands, partners indicated that they were less interested in working on the issue of agriculture, and

more interested in working on the areas of Employment, Transport/Planning, and Education.

Three Focus Area Group Leaders were therefore selected: David Ritchie from NHS Sefton agreed to lead

on Education, Owen Metcalfe (IPH) agreed to lead on Transport and Planning, and Malcolm Ward

agreed to lead on Employment

Focus Area groups meet to discuss approach and specific work plans

Following this selection, there was a discussion about the fact that it may be difficult to find good

examples of inter-sectoral collaboration at the national level, where Ministries have their own well-

established agendas. It was generally acknowledged that it is easier for different policy sectors to work

together at local level. One participant stressed that currently, there seems to be a lot of energy spent

on why HiAP should be implemented, while this should go into implementing existing findings and

making the process work. Caroline Costongs noted that it is important to start focusing on the ‘black

box’: why is it so difficult to move from theory to practice, why are some HiAP successful, while others

are not, and how can we use this information to come up with concrete answers and methodologies

that can be implemented by others?

Participants then divided into three groups to briefly discuss how to proceed with work in these three

Focus Group areas.

(Note: The discussion regarding the selection of the Focus Area Groups continued on the second day of

the kick off meeting)

17:00– 17:30 ∙ Session 4: Administration issues

Financial issues and reporting requirements

Yoline Kuipers, Project Officer at EuroHealthNet, presented information on reporting and finances

related to Crossing Bridges. The Cooperation Agreement was discussed, and partners were reminded

that the deadlines for technical and financial reports are September 2011 (Interim Technical & Financial

Reports) and June 2012 (Final Technical & Financial Reports).

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Also, it was emphasised that EuroHealthNet should be informed of transfers between items of eligible

costs, and that all original documents (e.g. boarding passes) should be kept for a period of 5 years.

Concerning the financial guidelines, information on the exchange rates and financial penalties was

discussed. Finally, Yoline showed examples of financial reporting templates.

Roisin Rooney gave some practical advice: amendments are possible but not advisable, because they

will delay the final payment; non-Euro countries are advised to have a Euro account to avoid the

consequences of exchange rate fluctuations; it is better to spend the money in the budget than owning

it at the end of the project, especially for non-Euro countries; the European Agency needs to be

informed of meetings.

17:30 – 17:40 ∙ Session 5: Round Up Day 1

Conclusions and Round Up day 1

Clive Needle concluded the first day thanking the participants for their input and asking them to ensure

correct financial management of the project (no amendments, keep to deadlines, keep to budget, and

always expect an audit).

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Day 2

Chair: Caroline Costongs, Deputy Director EuroHealthNet

Caroline Costongs opened and chaired the second day of the meeting. She indicated that implementing

a HiAP approach involves change, which is never easy to achieve. Project partners faced the challenge of

indentifying how they could spur change within their organisations to widen the scope of public health.

09:30 – 10:00 ∙ Session 1: Feedback from Focus Area group discussions

Each focus area leader sets out their agreements and plan of action.

The three Focus leaders then presented the outcomes of the previous day group discussions.

David Ritchie reported that the Focus Area Group on Education would like to start by finding examples

from the countries of the Focus Group members. A telephone or virtual meeting should be set up in May

to discuss the progress and findings, followed by a face-to-face meeting just before Project Meeting 2 in

July 2011.

Malcolm Ward reported that the employment Focus Area Group decided to focus on people at risk of

unemployment. The group would look at the problem both from the policy end (policies that have been

developed to address this problem) and from the action end (when and what type of did actions work,

and when have then subsequently become part of policy).

Owen Metcalfe indicated that the parameters of the focus groups work needed to be better defined

and that it would be important to set inclusive criteria or categories at the beginning that would define

the search for case studies. He also stressed the need to more clearly define the expected outcome/end

product of each Focus Group. Finally, he told the group that when good practices were discussed during

the Focus Area Group discussion, it was clear that often a ‘champion’ is involved in setting up and

implementing a HiAP approach. One person is often the driver for change, and this is an interesting

aspect to include and look into during the project.

Follow up discussion on selection of Focus Groups

When partners were asked again what Focus Area groups they would like to contribute to, it became

evident that participation in the ‘Employment’ Focus Group was weak. Malcolm Ward also indicated

that there is an EU co-funded initiative, being coordinated by HAPI, which is already looking into many

aspects of health and employment.

It was therefore decided to have only two Focus Group areas, one on Education (led by David

Ritchie/NHS Sefton) and one on Transport & Planning (co-led by Owen Metcalfe/IPH Ireland and

Malcolm Ward/PHW). Partners involved in WP4 were asked in which Focus Area Group they would like

to participate, and this resulted in the following scheme:

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EDUCATION TRANSPORT & PLANNING

FG Leader:

NHS Sefton

FG Leader:

IPH (Ireland) and PHW (Wales)

Associated Partners involved: EuroHealthNet

OEFI (Hungary)

NIZP-NIH (Poland)

GOG (Austria)

VENETO (Italy)

Associated Partners involved: EuroHealthNet

SZU (Czech Republic)

BZgA (Germany)

NIPH-IVZ (Slovenia)

Other Interested Partners:

IUHPE (Collaborating)

NIGZ (Netherlands)?

VIGeZ (Belgium)?

Other Interested Partners:

IUHPE (Collaborating)

Partners still unsure about their contribution were asked to inform EuroHealthNet and the relevant

Focus Group leaders of their final decision within a week.

Some participants reinforced the need to more tightly define the Focus Group areas. It was also noted

that a big problem in the area of convincing other policy areas to consider health impacts was that there

is still too little data and evidence in this field, and that this is an important issue that needs to be

addressed.

Yoline Kuipers suggested that group members should make use of the Equity Channel

(http://www.equitychannel.net/) to collaborate on the Focus Group topics. She will look into the

features and possibilities of the Equity Channel community, and come back to all the project partners

involved in WP4 with a proposal.

10:00 – 11:00 ∙ Session 2: Capacity Building at Organisational & Local

Policy Level

General outline of Capacity Development Plans

Ingrid Stegeman led project partners through the general outline of the Capacity Development Plans

(WP5). A Needs Assessment template should be ready for discussion at the second Project Meeting in

July 2011. Work undertaken during the DETERMINE project on capacity building could serve as a starting

point for this work.

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HIAP in Hungary

Agnes Taller, from the Hungarian National Institute for Health Development, depicted the current

situation regarding HiAP in Hungary. Hungary has a new government, and Public Health now sits within

a new Ministry of “National Resources”, which could provide a good basis for more inter-sectoral work,

although it is still unclear how this will work out. Her Institute’s funding has been cut, and their situation

is currently unsure. While inter-sectoriality is a core principle in the Public Health Programme, it remains

to be enforced in practice as resources are needed, while high-level representatives with decision

making power do not tend to sit on inter-sectoral committees.

Agnes informed all partners that during the Hungarian Presidency, on 14-15 April 2011, a meeting will

be held with representatives of Parliamentary Committees on Health from all EU Member States, where

HiAP will be discussed.

HIAP in the North West Region, England

Sharon Rawlinson, from NHS Sefton, said that the governmental situation in the UK has changed since

last May, and that this entails decentralization and more power at local level, where public health

decisions will now be made. As the regional infrastructures are being dismantled, there will be problems

in terms of network and collaborations.

Sharon then describes the “Living Well” approach endorsed by her organization. This approach is a call

to action that comprise of a series of key concepts to be taken into account when working locally to

decrease HI, including investing for health and better use of public resources. This fresh approach starts

from strengths rather than weaknesses and needs. Statements of direction include: All organization

investing in extending years of healthy life and tackling discrimination, poverty, and social injustice;

Environment and communities making it easy for people to live well; Children across all communities get

the best start in life and young people are supported to become successful adults; Public investment at

local level builds on local strengths to raise aspiration, build resilience, and release potential.

Sharon reported that local directors have taken this approach on board, and the White paper response

showed that this approach is actually having an influence. A transaction group has been formed, and

now capacity building as well as outcome measures are needed (e.g. social capital).

Open discussion on Capacity Building needs and approach to Needs Assessment

A discussion on capacity building was then opened. One participant indicated that it would be good to

apply and build on the DETERMINE capacity building approach (which identified 6 priority areas).

Caroline Costongs invited the partners to express their thoughts in terms of expectations: should the

capacity building focus on institutions or be more at national level? Would it be mainly skill training, or

should other types of training be prioritised?

Malcolm Ward stated that he would be ready to share training tools that were developed in the context

of the DETERMINE Project, as they will probably have a training module in place by the end of this

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month and a first capacity building training will be given this year. Sharon Rawlinson reminded

participants that the final aim of WP5 is to find ways to train public health officers to influence other

sectors and to take action.

11:20 – 11:40 ∙ Session 3: Dissemination Strategy

Plans for new portal / integrating Crossing Bridges into health-inequalities.eu site /

Choosing a project logo

Yoline Kuipers introduced the initial dissemination strategy for Crossing Bridges. Planned changes to the

current www.health-inequalities.eu website were described. The website, which is currently still

branded as ‘DETERMINE’ and focuses on DETERMINE outcomes, will be transformed into a more general

website that focuses on Health Inequalities and Health in All Policies in Europe. Current information on

the site will be kept and updated, while the outcomes of various different projects that EuroHealthNet

is involved in, particularly Crossing Bridges, the Joint Action on Health Inequalities and the Health

Inequalities Tender, will also be incorporated. The new site will be on-line by June 2011.

Possibilities for dissemination material were discussed, and the Partners suggested that newsletters,

videos, or cards/bookmarks would be a better option than leaflets.

Finally, several ideas for a logo were presented to the participants, who then agreed on a final version.

The logo for the Crossing Bridges project will be the following:

11:40 – 12:15 ∙ Session 4: Evaluation Plan

Presentation of detailed Evaluation Plan

Athena Linos presented the Evaluation Plan for Crossing Bridges. All major events will be evaluated via

questionnaires (handed in at meetings or emailed) assessing participants’ satisfaction, the agreement

between event objectives and outcomes, and the agreement with the time-line. Outcomes will be

accessed via evaluation indicators specified in the contract. EuroHealthNet will help PROLEPSIS set the

parameters to evaluate the Delphi method that will be applied in WP4. The evaluation plan will be

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finalized by the end of March 2011, and interim evaluation results will be presented during Project

Meeting 2. A meeting evaluation questionnaire was then completed by the Participants.

12:15 – 12:30 ∙ Session 5: Closing Remarks

Conclusions and closing remarks

Caroline Costongs suggested that the next Project Meeting should last 1.5 days, and that it should take

place during the first week of July 2011. Participants will be asked which on which days during this week

they are available, and the date suitable to most individuals will then be selected.

Roisin Rooney told partners that health inequalities has been included in DG SANCO’s 2011 Work

Programme, which is now focussing more resources on fewer priorities, and reminded partners that the

closing date to submit new project proposals under this year’s Work Programme is the 27th May 2011.

Caroline Costongs thanked the Project Partners for their contribution to the meeting and to the Project,

and stressed the importance of trying to make a difference by taking a step further, even if small,

towards addressing HI across all policies.

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Next Steps and Action Points:

Project partners are requested to take the following actions by the following dates, before the second

Project Meeting in July 2011:

Finance & Administration:

o By 18 March 2011: Send bank details to Yoline.

o By 18 March 2011: Yoline will send the finalized cooperation agreement. Please sign and

stamp two copies of this agreement and send them by post to EuroHealthNet.

EuroHealthNet will then also sign and send you a copy back.

o EuroHealthNet will send a Doodle with suggestions for a date for the second project

meeting.

Dissemination:

o June 2011: the first version of the renewed www.health-inequalities.eu and new section

on Crossing Bridges / HiAP (WP2) will be implemented. People will receive

communication when this is finalized and might be asked for feedback and suggestions

both before and after the website update.

o July 2011: The status of the website will be discussed.

WP4 (Focus Groups):

o A list of how associated and collaborating partners are distributed so far across the two

Focus Area Groups has been included in page 8 of these Minutes. Those partners that

were unsure about which Focus Area group to contribute to are asked to let

EuroHealthNet of their decision by 18 March 2011.

o By 18 March 2011: EuroHealthNet and Focus Group leaders will discuss objectives and

define parameters and then send guidelines and a template to Focus Group Members

by 25 March 2011.

o End of March: Focus Groups to start working.

o Each Focus Group is advised to have a meeting with the Group Members before the

next Project Meeting in July. Keep in mind that the Focus Area Group reports are due in

September 2011.

o July 2011: During Project Meeting 2 the initial outcomes and progress made by the

Focus Groups will be discussed.

WP5 (Capacity Building):

o NHS Health Sefton and EuroHealthNet will work on a draft Capacity Building Needs

Assessment Tool. This draft tool will be presented and discussed during Project Meeting

2 in July 2011.There will be a possible call for feedback on the tool before this meeting.