What is Health Impact Assessment?

 

Author: Ben Harris-Roxas, CHETRE

 

What is health impact assessment (HIA)?

There are many definitions of health impact assessment (HIA), however the most widely accepted one is from the Gothenburg Consensus Paper:

 

A combination of procedures, methods and tools by which a policy, program or project may be assessed and judged for its potential effects on the health of the population and the distribution of these impacts within the population. (ECHP 1999)

 

Other definitions emphasise that HIA:

 

    • Assesses plans, project, program or policies before
      they are implemented.
    • Predicts the health impacts of these proposals,
      including:
        • assessing the severity and likelihood of the identified
          positive and negative impacts;
        • determining whether these are direct or
          indirect impacts, and
        • assessing the distribution of impacts.
    • Recommends mitigation measures:
        • to maximise positive health impacts and minimise
          negative health impacts; and
        • engage decision makers so that they consider health
          impacts and the determinants of health in their
          deliberations. (Harris et al 2007)

 

These definitions highlight several of the key features of HIA that should be considered when undertaking HIA:

 

  • HIA can be undertaken on policies, programs or projects. It can also be undertaken on plans or other detailed strategic proposals.
  • HIA should be undertaken when it will add value to decision-making processes and where there is a commitment to acting on the HIA's recommendations.
  • HIA should be undertaken prior to the implementation of the policy, program and project that is being assessed.
  • HIA should assess the potential positive and negative impacts on health. This should seek to identify any unintended or previously unidentified potential impacts.
  • Health should be broadly defined to include assessments of health hazards and risks as well as ways in which health and wellbeing could be promoted and the social forces that impact negatively on health reduced.
  • HIA should look at the impacts on populations both directly and indirectly affected by the proposal.
  • HIA should include equity and the distribution of impacts as a central concern.
  • HIA should engage key stakeholders in the formulation of recommendations.

What are the key steps in HIA?

The steps that "define" a HIA are:

 

  • screening
  • scoping
  • identification of potential health impacts
  • assessment of the potential health impacts
  • decision-making and recommendations
  • evaluation and follow-up

 

These steps do not have to be undertaken in exactly the same way and different types of proposals will require different methods as part of each step. It is essential, however, that these five steps are understood as integral to any health impact assessment - they "define" HIA.

The Steps of HIA

The Steps of HIA

Source: Health Impact Assessment: A practical guide

 

How is HIA different from other kinds of impact assessment?

Impact assessment:

 

is a process whereby predictions are made about the future consequences or impacts of changes being made or considered. The concept is general. Within a specific context, such as health effects, there may be a wide range of outcomes for which impacts could be assessed, such as death, GP visits, absence from work, etc. Different contexts may emphasise different outcome measures, but the constant theme is future prediction, and in particular prediction of differences in outcomes under different scenarios of change against the status quo. (Miller & Hurley 2003: 200)

 

Health impact assessment is only one type of impact assessment and the other kinds of impact assessment include:

 

  • Environmental impact assessment
  • Social impact assessment
  • Integrated impact assessment
  • Strategic environmental assesssment
  • Biodiversity impact assessment

 

Each form of impact assessment emphasises the specific contexts within which the impact assessment takes place. Social impact assessment prospectively assesses the potential social impacts of a proposal. For example in NSW social impact assessment are usually required for the introduction of a new gaming (alcohol & gambling) venues within an area.

 

The impacts addressed in an environmental impact assessment are wide ranging with "health effects" forming just one component. For example, an environmental impact assessment of a major project may look at the impacts on the broad socio-economic environment, including human health, archaeological and cultural significance of the site,, noise and vibration, air quality impacts, greenhouse gas emissions, transport impacts and even changes in amenity with the intent of assessing the overall impact of the project on the environment.

 

The origins of HIA lie partly in environmental impact assessment of major projects, along with a desire to adress the social determinants of health and health inequities. The main differences between HIA as a standalone process (as opposed to how health has historically been considered in EIA) and other forms of impact assessment include:

  • A different context - HIA (outside of EIA) specifically assesses the potential impacts on human health including impact of the social determinants of health on outcomes such as life expectancy, well-being, mental health and other morbidity measures. The impact of the physical environment on health will be addressed as part of this;
  • Prospective impact assessment of proposed policies, plans, programs or projects - HIA is not limited to the potential impacts of a major development, such as the development of a new landfill site, but might assess the potential impacts of a proposed new taxation policy or a new chronic disease initiative on the health of a population. The importance of impact assessment of plans and policies has been recognised internationally through the rapid development of strategic environmental assessment.
  • A core principle of HIA is equity - a HIA considers how potential health impacts are distributed in the population, differential health impacts and whether these impacts are potentially inequitable. Other forms of impact assessment (Harris-Roxas et al 2004)

 

For further information about other types of impact assessment see:

 

HDA. Clarifying Health Impact Assessment, Integrated Impact Assessment and Health Needs Assessment, NHS Health Development Agency: London, 2004. Access PDF

 

Mindell J, Ison E, Joffe M. A Glossary for Health Impact Assessment. Journal of Epidemiology and Community Health, 57; 647-651, 2003.

 

Mindell J, Joffe M. Health Impact Assessment in Relation to Other Forms of Impact Assessment, Journal of Public Health Medicine, 25: 107-112, 2003.

Where does HIA sit in the planning and policy development process?

There are many methods by which health impacts can be considered, including:

 

  • Evaluation of health impacts and outcomes;
  • Health needs assessment;
  • Monitoring health indicators during implementation;
  • Tools such as the Aboriginal health impact statement, equity lenses, health checklists; and
  • HIA itself.

 

Knowing where HIA sits in relation to other methods for considering health impacts can assist in identifying when it is appropriate to use HIA. The following diagram outlines when an HIA should be undertaken in the planning or policy development process:

HIA in the Planning Process: When do you do it?

HIA in Planning Process

Source: Health Impact Assessment: A practical guide

 

HIA should not be used in place of sound needs assessment or planning but can be used to assess a draft policy/plan/program that has been developed as a result of needs assessment and planning. The HIA's recommendations can then be used to strengthen the proposal as well as informing the development of indicators for monitoring, evaluation and follow-up.

 

How is HIA different from health needs assessment?

Health impact assessment (HIA) is different from health needs assessment in that it seeks to assess the potential health impacts of an actual proposal (policy, program, plan, or project) - there is something tangible to assess.

 

In contrast a health needs assessment is conducted to develop a comprehensive picture of health issues in a particular community, population group or geographic area. The findings of a needs assessment are usually used to inform the development and/or revision of a policy, program, project or plan, ie. to develop a proposal.

 

HIA might then be used to assess the potential health impacts of the proposal developed in response to the "needs" or issues identified through the needs assessment. In essence, health needs assessment is something to be done before an HIA.

How is HIA different from monitoring?

Health impact assessment (HIA) is different from monitoring in that it seeks to assess (and predict) the potential health impacts of a proposal (policy, program, plan, or project) prior to implementation. In contrast monitoring is usually undertaken during and following implementation and the results of monitoring may be used to inform evaluation of an initiative.

 

An HIA's recommendations might be used to inform the monitoring process, e.g. recommending the type of information and indicatorsthat need to be collected to measure whether the potential health impacts eventuated. In terms of the planning or policy development cycle, monitoring is something that is done after HIA.

How is HIA different from evaluation?

HIA is undertaken prospectively - before the policy, program or project is implemented; unlike summative evaluation which is largely retrospective. HIA assists in the identification of negative and/or unintended consequences in advance of implementation. This provides an opportunity to ameliorate or amend the policy, program or project before implementation, saving not only resources but also maximizing the positive impacts from the proposed initiative.

 

Another key difference between HIA and evaluation is that it looks at the differential impact of the proposed policy, program or project (initiative) within the population. This includes (but is not limited to) looking at the distribution of impact in terms of:

 

  • socioeconomic status,
  • gender,
  • age
  • culture and ethnicity,
  • location, including proximity and locational disadvantage (i.e. rurality, disadvantaged neighbourhoods, etc),
  • existing levels of health and disability
    (Harris et al 2007, Harris-Roxas et al 2004).

 

In contrast, the equity of impacts is not necessarily a principle that underpins evaluation.

 

While HIA and evaluation are different it is important to recognise they are also linked. Evaluations of existing policies, programs or projects can inform an HIA. An evaluation of an existing initiative might include scenarios that are used to predict what the consequences might be of amending or changing the initiative, enabling the use of an HIA approach. Also an HIA can provide information about the types of indicators that should be monitored during implementation and considered as part of the evaluation of an initiative.

When should I do an HIA?

Resource constraints mean that it will not always be possible to conduct an HIA, and therefore it will be necessary to prioritise inquiries. (Nilunger et al 2002:32)

 

In order to make the most efficient use of available expert resources, it is necessary to be selective about what work is undertaken. (Scott-Samuel et al 1998:7)

 

Screening determines whether an HIA is appropriate or required. Screening ensures that time, effort and resources are targeted appropriately. Not all proposals will benefit from an HIA. (Harris et al 2007:8)

 

Not everybody who is developing a policy/program/plan or project needs to do health impact assessment. Although the decision to undertake an HIA should not be solely based on whether resources are available, this aspect does need to be taken into account. The decision to undertake an HIA or not and the level of HIA (rapid, intermediate or comprehensive) should be undertaken as part of the screening process - which is the first step in the HIA process and the process where projects, policies or programs are selected for HIA (Scott-Samuel et al, 1998).

 

The following issues should inform whether or not an HIA is required:

  • Is there a clear proposal to be assessed?
  • An initial assessment of the health impacts
  • Is it possible to influence decision-making?
  • The timing of the proposal being assessed
  • An initial assessment of the potential links between the proposal and health
  • An initial equity assessment of the proposal
  • Whether the nature of potential impacts is well documented
  • Whether other assessment tools are more appropriate
  • Availability of resources and capacity

 

More information on determining whether an HIA is required is available in HIA: A practical guide.

What's the rationale for undertaking an HIA?

 

There are broadly four reasons that are given for undertaking HIAs:

 

  • To identify hazards to health from the proposed development;
  • To reduce or eliminate potential risks to health arising from these hazards and/or undertake risk communication as part of this process;
  • To identify, and where feasible strengthen, the ways in which the proposed development can promote health and reduce health inequities; and
  • To identify and address underlying social, environmental and economic impacts of the development that will have both direct and indirect impacts on health.

 

The first two reasons would generally fit more easily within a health risk assessment/health protection focus while the last two identify ways in which health can be enhanced and underlying determinants of health addressed.

 

HIA enables decision-makers to enhance the potentially positive aspects and/or ameliorate the potentially negative aspects of the proposed policy, program, plan or project prior to implementation.

References

ECHP.Gothenberg Consensus Paper on Health Impact Assessment: Main concepts and suggested approach, European Centre for Health Policy, WHO Regional Office for Europe: Brussels ,1999. Access PDF

Federation of Swedish County Councils. Focusing on Health: How can the health impact of policy decisions be assessed? Landstrings Forbundet & Svenska Kommunforbundet: Stockholm, 1999. Access Guide

 

Harris P, Harris-Roxas B, Harris E, Kemp L. Health Impact Assessment: A practical guide, Centre for Health Equity Training, Research and Evaluation (CHETRE), University of New South Wales: Sydney, 2007. Access Guide

 

HDA. Clarifying Health Impact Assessment, Integrated Impact Assessment and Health Needs Assessment, NHS Health Development Agency: London, 2004. Access PDF

 

Miller B, Hurley J. Life Table Methods for Quantitative Impact Assessments in Chronic Mortality, Journal of Epidemiology and Community Health, 57, p 200-206, 2003.

 

Mindell J, Ison E, Joffe M. A Glossary for Health Impact Assessment. Journal of Epidemiology and Community Health, 57; 647-651, 2003.

 

Mindell J, Joffe M. Health Impact Assessment in Relation to Other Forms of Impact Assessment, Journal of Public Health Medicine, 25: 107-112, 2003.

 

Nilunger L, Schafer Elinder L, Pettersson B. Health Impact Assessment: Screening of Swedish governmental inquiries. Health Policy, 8(5): 30-32, 2002.

 

Scott-Samuel A, Birley M, Arden K. The Merseyside Guidelines for Health Impact Assessment. International Health Impact Assessment Consortium: Liverpool, 1998. Access Guide

What is HIA?

What does that word mean?
See our glossary of terms for explanations of HIA terminology

Introducing HIA