The World Health Organization (WHO) has called for the implications for health and the distribution of health impacts to be routinely considered in policy making and practice, through collaborative action by the health sector and non-health sector actors.1–5 While the need to address this has been understood for a long time, efforts by the health sector to work effectively with other sectors to influence their planning and policy development have been constrained, in part, by the lack of assessment tools and mechanisms to assess and negotiate recommended actions.5–8 Health Impact Assessment (HIA) has been identified as one of a limited number of methods that are available to address the social and environmental determinants of health prior to implementation of proposed policies, plans or projects designed to maximise future health benefits and minimise risks to health.1,9,10
The use of HIA in conjunction with Environmental Impact Assessment (EIA) processes has been adopted by a wide range of international agencies and groups, including the International Finance Corporation11,12 and the private sector as part of the Equator Principles – a financial industry agreement that sets out benchmarks for major project lending – and the International Council on Mining and Metals.13 It has also been adopted by a number of banks in Australia and New Zealand (NZ).14 Despite these efforts, health considerations are infrequently included in EIA.15,16
HIA is also being promoted as a cornerstone of healthy public policy;17,18 for example, its use has been adapted as a health lens assessment as part of South Australia's Health in All Policies initiative.19,20 Australia and NZ have been early adopters in developing guidelines and advocating for incorporating health within statutory EIA processes with a strong focus on major projects.16,21–26
There are now a number of papers and reports that describe the development of HIA in Australia. Three major strands have been identified. The first of these were attempts to incorporate HIA into EIA commencing with an NHMRC report in 1994 that argued HIA should not be a separate assessment but incorporated into EIA. This was followed by the development of HIA guidelines in 2001; however, incorporating HIA in EIA continues to be an aspirational goal. The second strand sought to expand the use of HIA beyond projects to include HIA of government policies and plans. This approach took a broader social view of health and used a wider base of evidence to assess impacts. The third and most recent strand included a focus on the distribution of impacts (equity).
Despite Australia's earlier role as an international leader in the development of HIA, the level and intensity of HIA in Australia has fluctuated over time.27,28 HIA remains poorly integrated into policy development and decision-making in Australia and NZ and there is limited legislative support for its use. The reasons for this are complex and still poorly understood but are thought to include:29,30
- the predictive nature of HIA and the fact that few HIAs are followed up to see if predictions eventuated, as well as the difficulty in determining if an impact was avoided due to the HIA;
- frequent difficulties in identifying ‘evidence’ of size and certainty of impacts;
- the lack of structures and procedures to allow the recommendations of HIAs to influence the policies, programs or projects of other sectors;
- the reluctance to introduce another impact assessment process into an already crowded and contested space;
- a lack of clarity about who should fund and conduct HIAs when government is the proponent;
- the reality that each state and territory develops their own approach to HIA in response to contextual and historical conditions;
- the lack of a robust research base that describes current practice, the effectiveness of HIA and factors affecting effectiveness; and
- difficulty in siting or locating responsibility for undertaking HIA inside government.
In New South Wales (NSW) and Victoria, state health departments funded capacity building projects to strengthen local capacity to undertake HIA. In South Australia, a health lens is being used in a similar way to HIA. In Victoria, the focus of their capacity building program was on Local Government and in NSW the focus was on health system capacity.31,32
The NZ Public Health Advisory Committee built capacity by developing a toolkit supported by an extensive training program, a program to fund evaluations and various other activities, as well as the ‘Learning by Doing’ program, to promote HIA activity. These measures did not result in the NZ Government broadly adopting HIA nationally, and has had relatively limited penetration into local authority planning activities, especially the resource consent process. Australian and NZ capacity programs have now been defunded (NSW in 2008, NZ in 2010).
There continues to be an interest by public health policy makers and other stakeholders in the use of HIA. However, the lack of detailed knowledge of the potential use of HIA is often opinion-based and not informed by research or practice. For example, the recent Australian Community Affairs Reference Committee response to the WHO Commission on Social Determinants of Health report noted that:
Although the Department [Commonwealth Department of Health and Ageing] conceded that HIA might be a useful tool we believe that they have the potential to be expensive and time consuming, and we believe that this needs to be taken into account in any further considerations of these.(4.55).
There is an important gap in our current knowledge of how HIA is being used, by whom and for what in Australia and NZ. It is also unclear if the HIA reports are adequate to confidently influence policy and decision-making.
The purpose of this paper is to provide an empirical basis for discussion of the use of HIA in Australia and NZ by describing the characteristics of HIAs undertaken. The paper also trials the use of a review package to assess the quality of the HIA reports (not the HIAs themselves).