Cross-sector dialogue for healthier policies: an overview of the 2006 health impact assessment conference.

Health impact assessment (HIA) is a practical approach for promoting wellbeing and health, with a focus on equity. It assists policy makers and planners who are working towards a healthy population to use a participatory approach in order to assess proposed policies or plans for their broad impacts on health and wellbeing.

Although hospitals, ambulances and white coats can dominate perceptions of "health", it is now well recognised that much of what affects people's health and wellbeing lies outside the health sector (National Health Committee 1998). Policies in areas as diverse as housing, taxation, transport, the environment and social development play a large role in determining health and equity outcomes. Consideration of the potential health implications of policies across government sectors has been underway in New Zealand for some time, but has only recently become more formalised. A range of bodies have used HIA, including agencies in the local government, urban planning and environment sectors, and in 2004 the Public Health Advisory Committee (a subcommittee of the National Health Committee) published its guide to policy-level HIA in New Zealand.

The 2006 HIA Conference was held in Wellington on 27 June, jointly organised by the Public Health Advisory Committee, the University of Otago, and Quigley and Watts Ltd (public health consultants). This conference was an opportunity to critically review progress within the transport, energy, urban design, housing, environment, social and local government sectors, and to discuss the future of HIA in New Zealand.

More than 70 people attended the day, representing a diverse range of organisations and perspectives. Participants comprised policymakers and planners across central and local government, along with public health and HIA practitioners from around the country. Organisations included:

* territorial local authorities and regional councils

* government agencies such as Housing New Zealand Corporation, ACC, Ministry for the Environment, Transit New Zealand, Ministry of Social Development and Ministry of Health

* public health units and District Health Boards Crown entities, including the Office of the Parliamentary Commissioner for the Environment, the Mental Health Commission and PHARMAC

* private sector organisations

* universities

* national organisations, including Local Government New Zealand and the Public Health Association.

The Honourable Pete Hodgson, the Minister of Health, opened the conference by calling for participants to discuss the future sustainability of HIA and challenging them to consider the embedding of HIA into public policy development processes over the longer term. This review of the conference will provide an overview of the day and summarise the issues that emerged from the conference on the benefits of HIA, its critical success features based on experience in New Zealand and overseas, and (in response to the Minister's challenge) the factors influencing HIA take-up and recommendations for addressing these.

OVERVIEW

Three case studies of HIA were showcased at the conference, two on urban development in greater Christchurch (Anna Stevenson, Karen Banwell) and Avondale (Shyrel Burr), and one on future energy scenarios (Helen Beaumont, Ian McAuley). The presentations from the case studies gave examples of the value of HIA in strengthening and improving both the policies themselves and potential health outcomes.

All three case studies identified enhanced relationships across sectors as an important and unexpected outcome. As a result of the HIA process, Christchurch City Council created a secondment role for a public health registrar to bring a public health perspective to the council's work. Case study presenters also cited indirect effects of HIAs. For example, Auckland City Council has adapted HIA methodology for their community wellbeing appraisal work, and the Parliamentary Commissioner for the Environment's Office also intends to use HIA tools in their methodology. (For further information on the Auckland and Christchurch case studies, see Stevenson et al. 2006:146-164 and Quigley and Burt 2006:165-175, both in Issue 29 of the Social Policy Journal of New Zealand.)

The early afternoon programme comprised three presentations on agencies' experiences of using HIA, including international (Rob Quigley) and New Zealand experiences of HIA (Martin Ward and Barbara Langford). Presentations highlighted the findings of research into the experiences of policy agencies and public health organisations in applying HIA, and agencies' decision-making on whether to undertake HIA. (For further discussion of the emergence and progress of HIA in New Zealand and overseas, see Signal et al. 2006:17-31 in Issue 29 of the Social Policy Journal of New Zealand.)

The conference then divided into two work streams to consider how to take HIA forward in local and central government settings. Discussion focused on the key facilitators and barriers to increasing the uptake of HIA. The final part of the day was a panel discussion, and Louise Signal and I gave concluding comments.

The Minister's call stimulated much exchange of ideas during the day. The following sections draw on the conference discussions, workshops, panel discussion and concluding comments regarding the future uptake of HIA in New Zealand.

BENEFITS OF HIA ACROSS GOVERNMENT SECTORS

Participants emphasised a range of benefits in using HIA. HIA was confirmed as an effective way to promote health, wellbeing and equity, and to increase recognition of the impacts on these of policy in sectors outside health. Participants agreed that a range of sectors can be better served through the use of HIA.

HIA also:

* helps to present a reasoned case based on evidence increases understanding of other agencies' roles

* facilitates greater collaboration, strengthens relationships across sectors, and is a vehicle for "plugging policy gaps" between agencies

* helps agencies to be innovative, to broaden their thinking and to identify potential unintended consequences of policies.

Local government experience, in particular, has been that HIA introduces key people (who had not been included previously) to the policy and planning process. For example, in the Christchurch case study, the HIA was a way to better engage with Ngai Tahu in relationship-building, which had been previously attempted but not achieved (Signal et al. 2006). The HIA process can facilitate and support more explicit consideration of equity issues within the policymaking process.

CRITICAL FEATURES FOR SUCCESS

The three presentations on New Zealand case studies identified several critical features for success in applying HIA, including the following.

* An inclusive process was important, with multidisciplinary input from a range of stakeholders.

* A previous history of collaboration (e.g. the Christchurch Healthy City Charter), openness to broad, cross-sectoral thinking, and exposure over time to health concepts were all factors that helped HIAs to be successful. Although existing strong relationships between agencies were beneficial, they were not a pre-requisite for success, as stronger relationships were an outcome of all three case-study HIAs.

* The use of HIA earlier in the policy process was preferable to later.

* The use of an independent facilitator in HIA workshops was effective.

In a presentation on learning from international experiences with HIA, Rob Quigley concluded that HIA can flourish with support, sustainable funding and key senior people acting as "champions" for HIA. He highlighted the following key features of effective HIA application in other countries.

* A specific support unit for HIA is a crucial ingredient for success. For example, in Scotland the absence of a support unit was identified as a major factor in HIA's lack of progress.

* Cross-party political understanding of the determinants of health has been important in international successes with HIA (e.g. Thailand and Sweden). Sweden has a structural emphasis on the determinants of health across sectors (e.g. their health strategy is focused on the determinants of health rather than health services or illnesses, and other sectors have a good understanding of wider health determinants).

* A sector-specific focus works well in Thailand's use of HIA.

FACTORS AFFECTING FUTURE UPTAKE OF HIA IN NEW ZEALAND

In the afternoon, Martin Ward and Barbara Langford presented the findings of New Zealand research, which introduced some of the enablers and inhibitors to the uptake of HIA. In response to the Minister's challenge at the start of the day, workshop and panel discussions covered a range of key factors likely to affect the future development and growth of HIA. These factors are outlined in Boxes 1 and 2 below.

Box 1 Factors That Would Facilitate Uptake of HIA

Better coordination and integration

Embed HIA into the existing policy and cross-sectoral processes of
agencies (e.g. Local Government

Act 2002 and Long Term Council Community Plan processes).

Use a partnership approach (multidisciplinary and/or cross-sectoral) in
moving HIA forward.

Use existing forums to promote HIA (e.g. Mayors' Forum, Local
Government New Zealand zone meetings).

Formal support for HIA

A support unit and a legislative basis for HIA are needed.

Sustainable funding is crucial.

HIA training is an impetus for future HIA activity.

Cross-party political understanding of the determinants of health was
important in international
successes with HIA (e.g. Thailand, Sweden).

There is a need to build the evidence of HIA's impact in New Zealand,
and to earn lessons from
early New Zealand work and from overseas experiences.

Champions

Key people who are passionate about HIA are important, but we should
not rely on a few
individuals.

Support from senior positions in policy and health agencies is crucial.
There should be a dedicated full-time equivalent (FTE) position to
support HIA in non-health
agencies (e.g. secondments, transfers of staff, "virtual" teams across
agencies).

There needs to be formal recognition of HIA skills and roles in job
descriptions and contracts.

Flexible use of HIA

An exploratory process is important (e.g. agencies can adapt HIA to
suit their purpose, it should
be seen as a learning process, it is acceptable to do small, simple
HIAs--i.e. "give it a go").

HIA is a flexible approach that can be used in different ways.

It is possible to use HIA for specific issues (e.g. to assess the
impact of public policies on obesity
as a health outcome).

Agencies outside health can use HIA to meet their own needs (e.g. to
meet statutory requirements,
consult more widely, etc.).

HIA is also a way for agencies to communicate their concerns to a wider
audience.

Box 2 Factors That Could Inhibit HIA Take-Up

Limited capacity

Reliance on external agencies (rather than policy agencies playing a
greater role in HIA) currently
limits the number of trained facilitators, and this also influences
perceptions of the potential cost
burden.

Demand-driven work or emergency issues takes precedence.

Sector boundaries

"Silo" thinking creates resistance to accommodating other sectors'
interests or messages.

The perception that the health sector is trying to "take over" other
sectors is an issue.

Limited understanding of HIA

There is a limited understanding of HIA and what it can achieve.

There is a perception that HIA is only relevant to the health sector,
and a common belief that the
agency has already considered health in its policy-making.

RECOMMENDATIONS TO TAKE HIA FORWARD IN NEW ZEALAND

Conference participants suggested that to ensure future sustainability of HIA, a package of measures should be implemented. The following actions were raised during the day's discussion (for further detail on these, see Signal et al. 2006).

In relation to a legislative and process mandate to consider health, wellbeing and equity it was recommended that:

* statutory recognition of HIA in the Public Health Bill be included as a non-binding provision

* the inclusion of public health considerations be made explicit in other sectors' legislation (e.g. as currently occurs in the Local Government Act 2002)

* HIA concepts be integrated into government agencies' policy development processes, including consideration of health, wellbeing and equity in specific processes such as memoranda of understanding between agencies, chief executive officers' contracts, and throughout the process of developing a policy for Cabinet consideration.

In relation to support unit for HIA it was recommended that:

* an HIA support unit be established to provide support for policy agencies undertaking HIAs, including training, research and evaluation

* careful thought needs to be given to the location of such a unit

* a partnership approach should be adopted for this unit that includes technical, academic and policy expertise, similar to the partnership that has led to the development of HIA to date.

In relation to sustainable funding it was recommended that:

* consideration be given to ways to ensure sustainable funding for HIA. This would likely involve funding for a support unit, as well as support for individual HIAs from a wide range of agencies undertaking HIA.

In relation to strengthening the health sector's involvement in HIA it was recommended that:

* the health sector has a key role to play in supporting HIA and this needs to be strengthened. One strategy may be for District Health Boards to include HIA as a standard part of service planning budgets.

CONCLUSION

This paper has provided a brief overview of the recent HIA conference in Wellington, and has outlined the response to the Minister of Health's call to consider the future growth of HIA in New Zealand.

Recent years have seen a growing impetus for HIA in this country, especially at the local government level. The conference was a valuable opportunity to bring together a wide range of sectors and organisations to review recent progress with HIA in this country and to identify lessons to be learned for future work. New Zealand's political context and organisational environments are increasingly receptive to HIA, with a strong focus on "whole of government" work and sustainable development. As described by one of the speakers at the conference, "the door to greater use of HIA is now ready to open".

Despite considerable progress in applying HIA in various settings, there is a need to ensure that this early momentum is maintained and increased. The conference highlighted a number of barriers to progressing HIA, but participants were also constructive in identifying the supports needed to overcome the barriers. Conference participants suggested a package of measures, including strengthening the mandate for HIA (and other ways to consider health) in various legislative settings, and establishing a support unit and sustainable funding for HIA.

REFERENCES

National Health Committee (1998) The Social, Cultural and Economic Determinants of Health, National Health Committee, Wellington.

Public Health Advisory Committee (2004) A Guide to Health Impact Assessment: A Policy Tool for New Zealand, National Health Committee, Wellington.

Quigley, R. and S. Burt (2006) "Assessing the health and wellbeing impacts of urban planning in Avondale: A New Zealand case study" Social Policy Journal of New Zealand, 29:165-175.

Signal, L., B. Langford, R. Quigley and M. Ward (2006) "Strengthening health, wellbeing and equity: Embedding policy-level HIA in New Zealand" Social Policy Journal of New Zealand, 29:17-31.

Stevenson, A., K. Banwell and R. Pink (2006) "Assessing the impacts on health of an urban development strategy: A case study of the Greater Christchurch Urban Development Strategy" Social Policy Journal of New Zealand, 29:146-164.

Louise Thornley (1)

Quigley and Watts Ltd

and

Department of Public Health

Wellington School of Medicine

(1) Acknowledgements

The author would like to thank Barbara Langford, Margaret Earle, Geoff Fougere, Louise Signal and Martin Ward for their comments on the draft of this paper.

Correspondence PO Box 25-201, Wellington, email [e-mail]