Strengthening health, wellbeing and equity: embedding policy-level HIA in New Zealand.

Abstract

Policy-level health impact assessment (HIA) is a formal approach for assessing the impact of policies on health, wellbeing and equity. HIA is used by policymakers across government and by those who may be affected by policy. This paper outlines efforts to embed HIA in New Zealand, including development of an HIA guide for New Zealand, training to support its use and the promotion of HIA to key government agencies. It briefly presents three New Zealand HIA case studies. The paper reviews the uptake of HIA in New Zealand and identifies a range of factors (including awareness of the role and potential value of HIA, training in HIA, access to HIA expertise, political and managerial support for HIA, resourcing and statutory recognition) that influence whether agencies undertake HIA. The paper then discusses the future of HIA in New Zealand, identifying the need for legislation to encourage HIA, the value of embedding HIA in policy processes and the importance of a dedicated HIA support unit. The paper concludes that considerable progress has been made at this initial stage of embedding HIA and that the approach has an important contribution to make in strengthening health, wellbeing and equity in policymaking in New Zealand.

INTRODUCTION

Policy agencies are increasingly recognising the influence their policies may have on the health and wellbeing of the population, and the impacts of the interaction of these policies with those of other sectors. The complex nature of these interactions makes it clear that a collective response is needed to ensure health improvement and a reduction of health inequalities. New ways of working across sectors are needed to find solutions, with new tools to assist the process. Health impact assessment (HIA) is one such tool, which is based on the recognition that the health and wellbeing of people and communities are greatly influenced by factors that lie outside the health sector, in areas such as housing, employment or urban design. It is a tool that can be applied at the "project" level (e.g. when a new road is being built in a particular community), but this paper focuses on the policy level (e.g. urban design, housing assistance policy, environmental policy).

Policy-level HIA provides formal tools to assess the impact of policies on health, wellbeing and equity. HIA can be used by policymakers in central, regional and local government in areas such as housing, urban planning and employment; by health policymakers; and by those who may be affected by policy. A New Zealand model for HIA has been developed and training is available. Policy-level HIAs have been undertaken in New Zealand with very positive results. This paper outlines efforts to embed HIA in New Zealand. It presents three New Zealand case studies, discusses the effect of HIA on policymaking and concludes with consideration of the future of HIA in New Zealand.

HIA DEFINED

HIA is a practical way to ensure that health, wellbeing and equity are considered as part of policy development in all sectors. It is defined as "a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population (European Centre for Health Policy 1999). It helps facilitate policymaking that is based on evidence and focused on outcomes, and encourages collaboration between a range of sectors and stakeholders. It is best undertaken when there are policy alternatives being considered and before commitment has been made (see Figure 1). However, it can be undertaken or revisited when revising or evaluating policy.

[FIGURE 1 OMITTED]

In theory, good policy analysis should consider all the relevant beneficial or adverse effects of policy options, both direct and indirect. In practice, however, the impacts of policies on health, wellbeing and equity are often not explicitly or even implicitly considered by sectors outside health, and certainly not in any formalised way. HIA enables these sectors to consider the wider impact of their policy on health, wellbeing and equity. It provides a systematic way to consider impacts, something not always possible in the typically pressured context of policymaking. This in turn promotes greater transparency in policymaking (Signal and Durham 2000). Policy HIA takes place in a complex political and administrative environment. It is not intended to make health, wellbeing and equity considerations paramount over other concerns; merely to raise their profile on the policy agenda.

THE STRATEGY OF EMBEDDING HIA

There has been a deliberate strategy to embed policy-level HIA in New Zealand. A number of factors have been important in getting policy-level HIA onto the policy agenda. Key among these were advice to the Minister of Health from the National Health Committee about the value of HIA (National Health Committee 1998), the support of a new government for HIA, and specific government policy regarding HIA. In 2000 The New Zealand Health Strategy, the overarching strategy for health in New Zealand, included as its first objective to "assess public policies for their impact on health and health inequalities" (Minister of Health 2000).

In 2004 the Public Health Advisory Committee (PHAC), a sub-committee of the National Health Committee, published A Guide to Health Impact Assessment: A Policy Tool for New Zealand (Public Health Advisory Committee 2004) to facilitate policy-level HIA in New Zealand. It was developed with the support of the PHAC secretariat, an external advisory group and international peer reviewers. The guide was drafted and then trialled on two case studies, one an HIA of a review of public transport funding policy and the other on the patenting of human DNA. It was modified as a result of these trials and launched in March 2004 at an HIA symposium. The guide has since been revised based on feedback from users and comments received by people attending HIA training (Public Health Advisory Committee 2005).

At the request of the Minister of Health at that time, PHAC promoted HIA in central and local government. At the central government level, PHAC has funded HIA seminars and screening workshops within agencies. Where these took place outside the health sector, the focus was on increasing the agencies' understanding of the wider determinants of health, often by selecting policies currently under development to screen their impact on health, and by making explicit links between the policies of the agency and health outcomes. In some cases, links were made with legislative responsibilities of the agency, showing how HIA could assist in meeting their responsibilities; for example, public health requirements of the New Zealand Land Transport Act 2003. Seminars and screening workshops that have taken place in the health sector focused on the methodology, the entry points for HIA in other agencies and "hands-on" practical examples.

Promotion to local authorities was largely in response to requests for assistance, often as a result of local government and public health unit attendance at HIA training workshops. However, a close relationship was developed with Local Government New Zealand, which provided an avenue for contact with local authorities. It was not difficult to sell the value of HIA in a context where local governments are looking for support to meet their statutory obligations under the Local Government Act 2002 to promote the social, cultural, economic and environmental wellbeing of their communities.

PHAC has provided or part-funded HIA expertise for agencies that wish to explore its relevance and/or undertake an HIA on a policy under development, including meeting with senior managers, being on call to facilitate scoping and/or appraisal workshops, mentoring HIA practice and reviewing processes and outputs. The expertise required was directly related to the degree of involvement of the sponsor agency. (2)

To support its efforts, PHAC established an intersectoral External Reference Group to provide advice about entry points into central and local government agencies and policymaking processes. PHAC also formed a valuable working partnership with academic, policy and technical experts in HIA and its related concepts. This group worked with PHAC to develop training and provide academic, policy and technical support to PHAC and agencies PHAC was working with. In order to gain insights from other jurisdictions, PHAC commissioned a literature review of international experience of policy-level HIA (Quigley 2005). The Ministry of Health provided PHAC with some funding assistance for these tasks.

A two-day HIA training course was developed by PHAC in partnership with the University of Otago, Mary Mahoney of Deakin University and Quigley and Watts Ltd. It was piloted at the 2005 Wellington School of Medicine and Health Sciences Summer School. Since that time, the course has been modified in response to participant evaluation, and provided in Auckland, Wellington and Christchurch to around 200 policymakers from across sectors, including many from District Health Boards and the public health sector. The course provides an opportunity for participants to gain hands-on experience of each of the steps in the HIA process on a real or hypothetical public policy, using the PHAC guide. "Graduates" of the course have taken a lead role in HIA activities since their training. They include the public health registrar who co-led the HIA of the Greater Christchurch Urban Development Strategy (Stevenson, Banwell and Pink 2006). The training team has also participated in three one-day workshops at the request of two public health units and the Ministry of Health.

EXAMPLES OF POLICY-LEVEL HIA

Three examples of policy-level HIAs undertaken in New Zealand will illustrate some of the ways HIA can be used. (3)

Future Currents

In 2005 the Parliamentary Commissioner for the Environment produced the energy scenarios report Future Currents: Electricity Scenarios for New Zealand 2005-2050, which set out to stimulate long-term thinking about energy issues in New Zealand (Parliamentary Commissioner for the Environment 2005). An HIA was commissioned to examine in greater detail the relationships between energy and health in two of the scenarios. The scenarios were based on the lives of two people, incorporating a mix of urban and rural, young adults and their children, and extended family members such as their grandparents. The scenarios also focused on Maori and on issues for low socioeconomic groups.

The HIA considered how the two scenarios could impact on economic growth, social connectedness and housing as the key pathways to health that might be affected. The potential impacts on the wider determinants of health included depopulation of rural areas, disconnection with cultural roots, inequalities in access to home energy efficiency programmes, and greater opportunities and risks for small businesses. These had potential health and wellbeing outcomes, some protective of health and others detrimental. These outcomes were selected for incorporation into the scenarios to further expand on potential impacts, and recommendations from the HIA were put forward to inform future policy work on energy alternatives. For example, in order to accrue maximal positive outcomes from the expected growth in small businesses under one of the scenarios, small-business support was identified as a way to prevent high rates of business failure, poor occupational health and safety and inappropriate work--life balance.

Avondale's Future Framework

An HIA (Quigley and Burt 2006) was undertaken of the impact of a draft plan Avondale's Future Framework (Auckland City Council 2005). The plan aimed to manage residential growth and issues affecting Avondale over the next 15 years, while strengthening the community and its economy and protecting the environment. The HIA included a rapid literature review and a workshop of key stakeholders. The majority of the potential health impacts of Avondale's Future Framework were categorised as positive. This is likely to be due to the community development approach undertaken to develop the framework, and the framework's broad but inter-related focus. Thirty-three of the 35 recommendations put forward to the Auckland City Council from the HIA have been accepted for implementation, some uniquely arising from the HIA.

Greater Christchurch Urban Development Strategy

An HIA was undertaken of the Greater Christchurch Urban Development Strategy, a collaborative community-based project to prepare a strategic plan to manage the impact of urban development and population growth within Greater Christchurch over the next 50 years (Stevenson, Banwell and Pink 2006). The HIA assessed the link between urban design, health determinants and health outcomes at a high level of strategic planning, and included consideration of air and water quality, housing, transport and social connectedness. Data were gathered for the HIA through workshops with key stakeholders, literature reviews and analysis of relevant submissions to previous community consultation processes. A second work stream focused on developing an engagement process with local Maori. The HIA was considered an extremely valuable process by participants according to an independent evaluation (Mathias 2005). Ngai Tahu now have a greater involvement in the development of the strategy and work continues to build this relationship. The development of a common language between disparate stakeholders was seen as key to future collaboration. Particular issues identified included ensuring an efficient public transport system, prioritising highly energy-efficient and sustainable low-cost housing, and involving residents in the design of new communities. The final report was accepted by the strategy steering group, and population health outcomes have become a key focus of the strategy planning group (Stevenson, Mathias et al. 2006).

REVIEW OF HIA UPTAKE AND USE

In 2006, at the Health Minister's request, PHAC reviewed the uptake and use of HIA. An independent review was commissioned of the reasons agencies gave for choosing or not choosing to carry out an HIA on any significant policy (Wyllie and Mulgrew 2006). Twenty-eight key informants from 13 different central and local government agencies were interviewed by phone. Of these agencies, five had undertaken or were in the process of undertaking HIAs, and eight had been approached by the PHAC project team but had not yet committed to an HIA.

In addition, the PHAC HIA project team interviewed 21 individuals who had been involved in the three HIAs outlined earlier in this paper--Future Currents: Electricity Scenarios for New Zealand 2005-2050, Avondale's Future Framework and the Greater Christchurch Urban Development Strategy (Ward 2006). The face-to-face interviews were undertaken no more than three months after the completion of the HIA and reviewed the positive and negative experiences of HIA and what effects the HIA had on the policy and on relationships across sectors. The results of both pieces of research are reported below.

New Zealand Agencies' Perspectives on Undertaking an HIA

Agencies that chose to undertake HIAs explained their decision by their recognition of the following.

* HIA is a tool that can address some public health legislative requirements (e.g. the public health objectives of the New Zealand Transport Strategy, and the "purpose" of the Local Government Act 2002 to "promote the social, economic, environmental and cultural wellbeing of communities".

* HIA can enhance political and public acceptance of a policy by identifying the potential positive effects on health and wellbeing.

* HIA can provide a focus for participation by stakeholders from other sectors and the community.

* HIA provides a framework to highlight potential positive and negative effects on health, wellbeing and health inequalities, including unanticipated effects.

Also, forming a partnership with the public health sector has been a strong motivation for some agencies (Ward 2006).

Key reasons agencies chose not to undertake an HIA were:

* lack of resources, time and staff capacity, and sometimes lack of confidence

* the agency did not see the value in HIA, possibly because their view of health was largely limited to a biomedical view of good health as merely an absence of disease

* the agency saw health as the responsibility of the health sector alone, even though most have a sense of how their own policies impact on health.

Some policy analysts who were persuaded by the value of HIA nevertheless had difficulty in getting the support of senior managers (Ward 2006).

Experience of Agencies that Undertook HIA

Those agencies that completed HIAs in New Zealand found that its structured approach extracted important new information and understanding out of existing planning data. HIA also significantly increased stakeholder engagement in the planning process. Local government experience was that HIAs brought key stakeholders to the table, who previously had not engaged. For example, HIA's emphasis on partnership, participation and protection, provided an entry point for Ngai Tahu, which had been sought but not previously achieved (Stevenson, Banwell and Pink 2006).

Council staff who participated in HIAs developed a wider understanding of the potential for public health units to take a broader role, beyond their statutory obligations, and of the relationship between public health and the "four wellbeings" that local authorities are required to address (social, economic, environmental and cultural). The public health agencies involved in the HIAs found that it helped them to establish working relationships with local authorities. HIA also gave public health staff more opportunity to contribute at a strategic level. Key stakeholders that participated in the HIAs found the process allowed them to promote their organisation's experience. All those interviewed found real value in being able to contribute to the planning process of the local authority, something that had not happened previously. It also provided a means of engaging with a range of disciplines and sectors, which all found rewarding and useful. HIA facilitated, increased and improved the quality of intersectoral collaboration. One public health staff member stated that it was a learning process for all parties:

   Overwhelming feedback from those who participated in this HIA was
   that it was an educational, enjoyable and valuable process that
   broadened their perspective on the role of urban design in achieving
   good health for the community. (Ward 2006)

Perceived Enablers and Barriers of HIA

Wyllie and Mulgrew (2006) identify factors that key informants perceived as enabling or impeding HIA. These are discussed below in relation to international evidence drawn from the review commissioned by PHAC (Quigley 2005) and the experience of the authors. These factors are drawn together in Figure 2 as the determinants of whether an organisation chooses to undertake HIA.

[FIGURE 2 OMTITED]

Factors that enabled HIA included:

* an understanding of the potential impact the agencies' activities have on health and wellbeing through the wider determinants of health (the research showed a strong correlation between this understanding and the interest in and use of HIA)

* the ability to see how the HIA process might assist in meeting statutory responsibilities (e.g. for local authorities to meet the requirement to promote and protect community wellbeing)

* the ability to see how HIA would fit into the policymaking process and contribute positively to the policy

* confidence to undertake the HIA process, most often gained by HIA training and access to public health and HIA technical expertise

* political support and support from senior management, and HIA "champions" within the agency (this was seen to be of critical importance)

* funding and expertise provided by the public health sector for getting HIA started (policy agencies were more likely to provide resources after an experience with HIA)

* positive experience of HIA (this was a predictor of further commitment to the HIA approach)

* access to a locally based tool (this factor is seen internationally as important, and there was a generally positive response to the PHAC tool)

* statutory recognition or a requirement for HIA (this was put forward as an important incentive for HIA: one interviewee questioned why an agency would bother to spend time and resources on an activity that was not required by law)

* an HIA support unit (this is consistent with international findings that show a correlation between the establishment of an HIA support unit and the sustainability of HIA).

Barriers to HIA included the following.

Cost was the barrier most often identified by interviewees in New Zealand and internationally. A strong theme was that the health sector would need to provide the entire funding for an HIA. However, in other countries the policy proponent is expected to fund the HIA.

* Lack of capacity was also seen as a barrier, especially for some central government agencies who see HIA as yet another call on their time. This is also consistent with international findings and has led overseas to an exploration of how HIA might be integrated with other impact assessment processes.

* Confidence was an issue for many of the New Zealand interviewees who had not been involved in an HIA. Interviewees who had undertaken HIA training and had access to public health and technical support were those with the confidence to take HIA forward.

* The perception that current policy development processes are sufficient to identify potential health impacts was also a barrier, especially in central government agencies. The research found that few agencies use formal processes to identify health impacts, and many central government agencies rely on consultation with the health sector at the end of a Cabinet paper process when there is little opportunity to influence policy direction.

* The confidentiality of the policy process, especially at central government level, could make cross-sectoral stakeholder involvement difficult. However, this does not preclude an HIA being carried out "in-house".

* Lack of confirmation and support by senior managers were consistently given in the New Zealand survey as significant barriers.

* There was a common perception among policymakers who had not experienced an HIA that it would delay the policy process by being an additional process to be completed. For those who had experienced an HIA, its systematic approach assisted rather than delayed the policy process.

Local and Central Government Uptake

Policy-level HIA has been picked up by some local governments and is gaining momentum. Local authority policymakers quickly see the links between the wider determinants of health, and the social, cultural, environmental and economic wellbeing of their communities. They also see HIA as a vehicle to bring the community and other key stakeholders together and to develop intersectoral working relationships. HIA appears to be a good fit with local authority routines and ways of approaching policy issues.

Central government agencies have been slower to take up HIA, although the Parliamentary Commissioner for the Environment, the Ministry of Health and the transport sector have undertaken policy-level HIAs. There was a view among some central government agencies that existing policy processes are sufficient to pick up health impacts, and that HIA would be just another layer in an already complex process. Central government does not have the strong legislative drivers that local government has--with the exception of the transport sector, which, in spite of legislation with strong public health purpose and objectives has not yet embedded HIA into its policy processes. There was, however, a recent HIA carried out of the Greater Wellington Regional Land Transport Strategy, which identified areas where the strategy should be modified for greater health improvement.

HIA GOING FORWARD

International experience has found that an explicit process such as HIA is necessary to give policymakers sufficient technical information on the expected health impacts to influence decision making. A consideration of health and wellbeing and of health inequalities needs to be embedded into the policy development processes if policies from other sectors are to have a positive impact on health. Building processes, concepts or ideas into existing rules and procedures has come to be known as "institutionalisation". Banken has discussed the need to institutionalise HIA, to build it into existing rules and procedures (Banken 2001, 2003).

This "institutionalising" of the consideration of health impacts is more likely to be effective if it happens in a number of ways at a number of different levels. Encouraging non-health sectors to embed the consideration of public health implications into policymaking in any meaningful way will require the guidance of statutory and regulatory recognition, the provision of assessment tools, expertise and training, and the modelling and support of the health sector.

At Central Government Level

Internationally, HIA at a policy level has remained largely an activity undertaken without statutory requirement by those who recognise its benefits. International calls for the need to "change the rules governing systems of decision-making" to institutionalise HIA suggest that legal frameworks constitute one of the strongest means for changing these rules and that although local-level policies may not need a formal framework, legal frameworks are most likely to be necessary at the national level (Banken 2003).

Consideration of health implications can be grafted on to policy analysis at Cabinet level. As a stand-alone strategy this is unlikely to make a difference, especially if it is a "tick box" requirement on completion of a Cabinet paper. However, as an addition to other approaches, it could serve to reinforce the importance of ensuring that policies do not impact negatively on health. Cabinet papers could include a requirement to show how health, wellbeing and equity had been considered during the development of the proposal. This would be a departure from current practice which requires departments and/or ministers to assert that a policy does not have an impact in key areas.

The State Services Commission, the Office of the Auditor-General, the Ministry of Economic Development (in terms of regulatory impact) and the Treasury all have roles in monitoring other government departments. This monitoring could be used as an effective mechanism to ensure health, wellbeing and equity are considered in policy development across government. For example, statements of intent from all relevant agencies could be monitored for commitment to these considerations.

At Local Government Level

Local government in New Zealand has legislative responsibilities where HIA can assist local authorities in meeting their public health obligations. The Health Act states that it is the "duty of every local authority to improve, promote, and protect public health within its district". The "four wellbeings" in the Local Government Act 2002 (social, economic, environmental and cultural) are congruent with the wider determinants of health and are increasingly being recognised under this label. Implicit in this legislation is the idea that health in its broadest sense is a local government responsibility.

HIA fits well with the democratic responsibilities of local government that seek community participation in local decision making. In addition, local government is required to identify community outcomes by consulting with the community. The HIA process can provide local government with a tool to include communities and other key stakeholders. For example, Greater Christchurch succeeded in engaging local Maori in the Urban Development Strategy discussions through the HIA process (Stevenson, Banwell and Pink 1996).

Effective HIA assumes an understanding of the wider determinants of health and recognition of the impact that policies outside health can have on the wellbeing of the population. This understanding is limited in many agencies where health concepts may be viewed in a disease framework and may therefore be considered irrelevant. HIA must therefore rely on experienced practitioners to broker and guide the process, at least initially.

International experience shows that institutional impetus for HIA is more likely to be maintained where there is a dedicated HIA support unit or team (Quigley 2005). Such a team is involved in promoting HIA, supporting agencies that undertake HIA, and providing a resource for evidence and evaluation. Ideally, a dedicated team would have a "whole of government" remit, with a partnership between a mix of agencies for sustainability. The PHAC secretariat, together with staff from the University of Otago and independent impact assessment consultants, has in effect fulfilled the role of an HIA support team to date. There is a strong argument for such a model to be continued.

At a local level, some public health units have been performing the functions of HIA support units. Some of the major centres, especially Auckland, Wellington and Christchurch, have shown strong leadership in this area. This HIA promotion and support could only have happened with contracting support from the Ministry of Health in the localities. HIA is now appearing in service plans for Ministry of Health contracts; it is important that funding models are flexible enough to support HIA and other intersectoral collaboration.

Capacity building needs to occur both within and outside the health sector. Because policy-level HIA is a relatively new discipline, skill, confidence and experience need to be built.

CONCLUSION

This paper charts the considerable progress made in embedding HIA in New Zealand in recent years and demonstrates its role in focusing policy development on health, wellbeing and equity. The paper also identifies a number of strategies to progress the use of HIA. These include the insertion of HIA in legislation and policy processes and the establishment of a dedicated HIA support unit to provide HIA advice, training, research and evaluation. With changes such as these, HIA has the potential to make a more consistent, systematic and substantial contribution to strengthening health, wellbeing and equity in policymaking in New Zealand.

(1) Acknowledgements

The authors would like to thank all those involved in HIA training, research, practice and advice in New Zealand in recent years for their contribution to the development of HIA in New Zealand and to the story told in this paper.

REFERENCES

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(2) The "sponsor agency" is the agency with the policy to be assessed.

(3) Two of these examples are discussed in more detail in other papers in this issue (Quigley and Burt 2006; Stevenson, Banwell and Pink 2006).

Louise Signal (1)

Department of Public Health

Wellington School of Medicine and Health Sciences

Barbara Langford

Public Health Advisory Committee Secretariat

Rob Quigley

Quigley and Watts, Public Health Consultants

Martin Ward

Impact Assessment Specialist

Correspondence

Louise Signal, PO Box 7343, Wellington South, email [e-mail]