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0 STRENGTHENING HEALTH, WELLBEING AND EQUITY:
EMBEDDING POLICY-LEVEL HIA IN NEW ZEALAND
Louise Signal
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
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 ADDIN EN.CITE European Centre for Health Policy199966566527European Centre for Health Policy, Health Impact Assessment: main concepts and suggested approach - the Gothenberg consensus paper1999BrusselsWorld Health Organization Regional Office from Europe(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.
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 ADDIN EN.CITE Signal200065765717L N SignalG DurhamHealth impact assessment in the New Zealand policy contextSocial Policy Journal of New ZealandSocial Policy Journal of New Zealand11-26152000(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 ADDIN EN.CITE Minister of Health200025825827Minister of Health,The New Zealand Health Strategy2000WellingtonMinistry of Health(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 ADDIN EN.CITE Public Health Advisory Committee200466866827Public Health Advisory Committee,A Guide to Health Impact Assessment: a policy tool for New Zealand2004WellingtonPublic Health Advisory Committee(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 ADDIN EN.CITE Public Health Advisory Committee200566266227Public Health Advisory Committee,A Guide to Health Impact Assessment: A policy tool for New Zealand. Second Edition2005WellingtonNational Advisory Committee on Health and Disability(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.
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 ADDIN EN.CITE Quigley200567267227Robert Quigley Review of International Policy-level HIA for the Public Health Advisory Committee2005WellingtonPublic Health Advisory Committee(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.
Future Currents
In 2005 the Parliamentary Commissioner for the Environment produced the energy scenarios report Future Currents: Electricity Scenarios for New Zealand 20052050, which set out to stimulate long-term thinking about energy issues in New Zealand ADDIN EN.CITE Parliamentary Commissioner for the Environment200567067027Parliamentary Commissioner for the Environment,Future Currents. Electricity scenarios for New Zealand 2005-20502005WellingtonParliamentary Commissioner for the Environment(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 t h e i r g r a n d p a r e n t s . T h e s c e n a r i o s a l s o f o c u s e d o n M o r i a n d o n i s s u e s f o r l o w s o c i o e c o n o m i c g r o u p s .
T h e H I A c o n s i d e r e d h o w t h e t w o s c e n a r i o s c o u l d i m p a c t o n e c o n o m i c g r o w t h , s o c i a l c o n n e c t e d n e s s a n d h o u s i n g a s t h e k e y p a t h w a y s t o h e a l t h t h a t m i g h t b e a f f ected. 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 worklife balance.
Avondales Future Framework
An HIA (Quigley and Burt 2006) was undertaken of the impact of a draft plan Avondales 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 Avondales Future Framework were categorised as positive. This is likely to be due to the community development approach undertaken to develop the framework, and the frameworks 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 M o r i . T h e H I A w a s c o n s i d e r e d a n e x t r e m e l y v a l u a b l e p r o c e s s b y p a r t i c i p a n t s a c c o r d i n g t o a n i n d e p e n d e n t e v a l u a t i o n A D D I N E N . C I T E <