on Medicare and the money needed to provide illness services. Similarly, in the UK, health is synonymous with the National Health Service (NHS).
The majority of the population thinks of health as being far more than access to the services needed because of ill health. For planners seeking to develop healthy communities, consideration of health does not equate to healthcare or health systems. For health professionals who are striving to get policy makers to consider the health implications of their actions, the meaning ascribed to health falls well outside the healthcare system. Health policy increasingly needs to be thought of as ‘all policy’. The reality is that policy and practice both within health and outside it are still confined to ‘silos’.
To adopt a problem oriented approach to health policy, therefore, the traditional boundaries of discussion need to be blurred. To be of value and create new ways of thinking about policy problems, one must first ‘problematise the problem’. HIA is a process that seeks to get health considerations onto the policy agenda and thus by necessity must focus on attempts to breakdown ‘silo thinking’.
ANALYSIS OF HEALTH IMPACT ASSESSMENT
An analysis of the origins of HIA shows that it is a highly contested concept. It has a range of meanings and is intended to fulfil a variety of roles depending upon local, regional or even historical origins. Australia’s involvement in the development of HIA was formalised in the 1990s with the publication of national guidelines called the National Framework for Environment and Health Impact Assessment (Ewan et al. 1994). These guidelines were designed for use within the environmental health policy context and were based on the thinking that underpins Environmental Impact Assessment (EIA). They were subsequently developed into the enHealth Health Impact Assessment Guidelines (2001).
In the late 1990s and early 2000s, the Department of Heath and Ageing (DHA) funded several other pieces of research into HIA. These included work on its potential role as a public health policy tool (Mahoney et al. 2002), and the legislative and administrative dimensions of HIA at state and territory level (National Public Health Partnership [NPHP] 2005). Another study focused on strengthening equity considerations in policy making, which included the development of a suite of analytical tools based on HIA (Mahoney et al. 2004).
HIA has a history of approximately 50 years and can be described as a concept still being developed. Analysis of early writings on it show that one of the prime motivators for its development was as a mechanism for rectifying perceived problems in the policy or planning processes of government. Depending on the context in which its introduction was advocated, these problems tended to relate to, but were not exclusively limited to, environmental management, population health, or government agendas seeking to reduce inequalities or disparities within the population. These early writings show that HIA is not a fixed concept with a unitary form based on a set of clearly defined and unanimously agreed principles, but is a highly contested field within and between countries and disciplines.
In the latter half of the 1990s, interest in HIA was rekindled with the publication of papers in leading health journals in England and Canada. These described new policy problems and advocated a new form of HIA focused on public health and policy development. The common theme within them was the argument that increasing attention needed to be paid to the potential role that public policy plays in determining population health outcomes. HIA, it was argued, would help governments to assess the level and severity of the impact that policy proposals would have on health outcomes. This form of HIA has become known as policy HIA or strategic applications of HIA (Abrahams et al. 2002).
As a consequence of this new interest in HIA, a great deal of effort was put into developing a consensus view of the areas of commonality within it. The Gothenburg Consensus Paper (GCP) was produced after extensive international consultation and it defines HIA as:
a combination of procedures, methods and tools by which a policy, program or project may be judged for its potential effects on the health of the population, and the distribution of those effects within the population.
The GCP conceded that there are problems with achieving a unified understanding of HIA, arguing that the ‘ramifications of the HIA process are so broad that consensus around aspects … must be built up gradually’ (ECHP 1999 p 2). It calls for agreement on tools for the screening policies for their potential impacts, consideration of the implications of participation in decision-making processes of government, processes for communicating risks, and mechanisms for negotiating changes to proposals so that potential negative or detrimental impacts on health can be avoided prior to the decision being made, as well as a strengthening of the potential positive impacts. The GCP sets out four broad elements that have, in effect, come to describe the attributes important to and underpinning virtually all forms of HIA. These include:
- consideration of evidence about the anticipated relationships between a policy, programme or project and the health of the population (understood as total population and groups within the population);
- consideration of the opinions, experience and expectations of those who may be affected by the proposed policy, programme or project;
- provision of more informed understanding by decision makers and the public regarding the effects of the policy, programme or project on health;
- proposals for adjustments/options to maximize the positive and minimize the negative health impacts.
- consideration of the opinions, experience and expectations of those who may be affected by the proposed policy, programme or project;
(ECHP 1999 p 5, bold and italics in original)
Despite striving for a consensus, subsequent writings indicate that there are still inherent differences in people’s understanding of HIA depending upon the perspective they hold, the purpose they ascribe to it, and the context in which it is to be applied. For example, many people describe HIA purely in functional terms, that is, as a tool or instrument (Lock 2000); others describe it through its possible structure, that is, as a framework or approach (Berensson 1998); and others describe it in terms of the innovative potential that it offers for addressing problems differently, that is, as a concept or way of thinking (Scott-Samuel 1998).
Much attention has been paid in the research to practical dimensions such as the development of tools and frameworks, techniques for accessing evidence of likely impact and reporting on the outcomes of completed studies that have used HIA. More recently, attention has been directed to evaluative studies, which examine the value that HIA offers policy makers in influencing decision-making processes (Department of Health and York Health Economics Consortium 2006; Taylor et al. 2003). Little attention has been paid to the implications of the multiple and contested meanings of HIA or the fact that it has emerged as a response to a range of quite different policy problems.
This chapter focuses on the role of HIA in addressing two specific policy problems and explores the implications of its application in these contexts in terms of Australian health policy in it broadest sense. The term ‘policy’ is used generically to describe any new or modified policies, projects, programs, or services that are developed by governments at all levels and which have the potential to impact upon health, defined broadly.
IDENTIFICATION OF THE PROBLEM
Bacchi (1999) in her book, Women, policy and politics: the construction of policy problems, argues that it is impossible to separate the objects or targets of a policy from the way they are spoken about or represented. Any issue is an interpretation and, as such, involves judgment and choice. Policy proposals, therefore, cannot be separated from interpretation, they contain them, they frame the way(s) in which the issues are responded to and these become interventions, which have problematic outcomes. Bacchi argues that we give a particular ‘shape’ to social problems through the way we speak about them and the way(s) we recommend they be dealt with. There are very strong parallels between her work and the development of HIA that have direct relevance to both the policy context and to this chapter. Her specific interest is in the implications of problematisation, or problem representation, rather than the problem per se. Specifically she is interested in three broad areas: ‘What’s the “problem” represented to be; what presuppositions are implied or taken for granted in the problem representation and what effects are connected to this representation of the problem’ (Bacchi 1999 pp 1–2).
With HIA there are multiple ways of understanding or interpreting: What’s the problem represented to be? what are the presuppositions implied and taken for granted within these representations, and the effects or implications of the identified solution(s) to resolving the problem? The framing of policy problems results in the development of new tools or approaches to respond to these areas. HIA is therefore both a product of representations of particular policy problems and the subject of these representations. It is beyond the scope of this paper to examine all of the possible representations of policy problems and thus the forms that HIA can take. These can be sliced according to form, function, intended outcome, context or discipline base. To use an analogy, they can be likened to the multiple ways in which a cake can be sliced as well as the various types of cake that might warrant different types of slicing.
This chapter focuses on the two most common representations of HIA based on two policy problems:
Bacchi also cautions that there are no assumptions in the use of this approach or in the language that is used. There is no one reality that stands outside representation. That is, there is no form of reality or truth against which claims can be judged. All are representations, and, as such, are not right or wrong, better or worse. ‘The goal in taking this approach is to examine the ways in which public policy problems achieve their reality in language’ (Bacchi 1999 p 37) and as such they illustrate the inherent tensions that will always lie within the political and policy development process. For HIA, the implication of this is that despite the development of a body of literature and methodological tools to support the policy development process, there will never be one agreed form of HIA that can or should be applied to all contexts. As a form of intervention that supports perceived social, political, or environmental problems, HIA will always be context bound. This section introduces each of the problem representations and their links to HIA. The problematisation of each of these is examined in the subsequent section.
FRAMING THE PROBLEMS AND LINKS TO HIA
HIA as a solution to achieving healthy public policy
In the late 1980s and early 1990s, the concept of healthy public policy was introduced by health professionals who were seeking to extend the scope of health policy beyond the traditional medical health paradigm. The basic tenet underpinning healthy public policy is that health is influenced by a range of factors largely outside the control of the individual and the healthcare system and that the focus of activity needs to be directed at a population rather than on an individual level (Milio 1981). According to the World Health Organization (WHO), healthy public policy is characterised by an explicit concern for health and equity in all areas of policy and by accountability for health impacts (WHO 1998). The main goal of policy framed this way is to create environments where people can lead healthy lives and, in order to do this, it is necessary to address inequity and disadvantage at population levels. So the healthy public policy agenda sought to be transformative, emancipatory, political and health promoting (Baum 1998; Simpson et al. 2004), rather than health protecting.
In framing the problem that led to the development of HIA linked to the achievement of healthy public policy, the social model of health is based on the assumption that health status is not only determined by the health services people have access to, and by their own behaviour, but by a range of factors outside their control, including government policies. Health policy and the health sector, therefore, cannot deliver improved health outcomes alone and so health becomes everyone’s business. Policy makers in all sections of government must either be required to account for, or encouraged to consider, the likely impacts of their actions on the health of the population in order for public policy outcomes to be considered healthy.
To achieve this, a new approach is required which can assist the decision maker to identify the health impacts that are likely to occur as a consequence of their actions, thus ensuring that healthy outcomes are created. HIA is represented as a support tool for decision makers that can be used to identify potentially negative impacts and ameliorate these as well as to identify and strengthen actions, which can have positive or beneficial health outcomes. The potential health impacts might be positive, negative or unknown and they are not spread evenly or consistently across the population. The use of HIA in a policy context allows for health considerations to be included where they currently are not, for evidence of likely effects to be factored into the decision making, and for the trade-offs likely to arise to be considered prior to a commitment to proceed. The driver for its use is thus the avoidance of something accompanied by a desire to ensure that health considerations are given high priority within government.
As the focus of action rests both outside the health sector and inside it, proponents of healthy public policy have advocated the need for intersectoral working to support the achievement of what is essentially ‘health for all people’. In this problem representation, health practitioners must accept that they do not control the achievement of health outcomes or the mechanisms by which health is ‘delivered’ to the population. All policy becomes health policy and the achievement of positive health status requires interventions or actions from a variety of sources, largely outside the control of the health sector. The risks associated with this representation are that the concept of health is so broadly defined that responsibility for it rests everywhere and nowhere simultaneously.
HIA as an extension of EIA
In 1969 the National Environmental Policy Act (NEPA) was introduced in the US. Within 2 years of its introduction EIA processes were established. One of the purposes of this legislation was the promotion of effort ‘which will prevent or eliminate damage to the environment and biosphere and stimulate the health and welfare of man’ (Banken 1999 p S27). Despite prior work, it seems clear that public health started to be formally integrated into EIA processes in the 1980s as a consequence of the release of the WHO report on the health and safety components of EIA. This report recommended the use of the risk assessment and management processes within EIA focusing on toxicological aspects (WHO 1987). This was one of the principal drivers for the development of HIA.
As stated above, Australia has a strong tradition of this form of HIA. Other countries with a similar tradition include New Zealand, Germany, Canada, UK, Thailand and countries in receipt of World Bank or (former) International Monetary Fund (IMF) development funding, including countries in Africa. Countries with a strong tradition of using EIA processes within environmental decision making have procedures enshrined in law and have clearly established protocols to guide the use of EIA or HIA, as well as clear expectations of the types of outcomes required by law. The goal of this form of HIA is the protection of human health. It focuses on specific threats to community or public health and it seeks to forecast the likely unintended consequences of changes to the physical environment. The enHealth HIA guidelines define it as:
The process of estimating the potential impact of a chemical, biological, physical, or social agent on a specified human population under a specified set of conditions for a certain time frame.Stay updated, free articles. Join our Telegram channel
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