What makes health impact assessments successful? Factors contributing to effectiveness in Australia and New Zealand


We found that the factors that expanded or refined the understanding of ways to influence
effectiveness of HIAs could be broadly grouped into the Harris-Roxas model headings:
Process related factors that include factors essential to HIA (necessary) and other
process related factors that are not essential (contingent) but can enhance the impact
of HIAs and broader contextual factors outside of the HIA process (see Table 2).

Table 2. Factors influencing effectiveness in Australia and New Zealand

Process factors

There are processes that are inherent to HIA that some participants felt made it a
more effective tool than other inter-sectoral processes in which they had previously
been involved. These include the stepwise process, the flexibility of HIA for adaptation
to local contexts, and the legitimacy provided by evidence. Each of these features
is discussed below.

Purposeful and structured stepwise process

The stepwise process was identified as a key strength of HIA because it made meetings
and engagement in the process purposeful and structured. Respondents described how
having meetings associated with the key steps of HIA (screening, scoping, assessment
etc.) differed from ‘normal’ meetings in that there was a clear purpose to the meetings
and that the meetings reflected progress being made in the HIA process. The structured
‘scientific’ process was also seen as creating or enhancing legitimacy. Having recommendations
as an outcome of the process was also identified as being important.

“Before …the people are in there but you’re not working together, you’re just providing
your input and going “oh yeah whatever” … But then this way it was actually a combined
effort… doing this [HIA] helped work out how to bring the cross divisional multiple
professions together to work on a document that really was all about delivering sustainable
communities”. (HIA working group, Engineering)

Flexibility

The flexibility of the HIA allowed the stepwise process to be adapted to local contexts,
to be culturally appropriate and to adjust to changes. Engagement with communities
and cultural appropriateness was a particular feature of the New Zealand HIAs. Some
HIAs utilised an HIA framework (Whanau Ora) designed specifically to be used on proposals
that were likely to affect Maori health. The flexibility of HIA also allowed participants
to adapt the process to changing circumstances. In some cases HIAs would be re-scoped
part of the way through the process. For example, a decision that the HIA was meant
to inform may have been made earlier than expected, and the HIA would then be re-scoped
to focus on another facet of the proposal that could be influenced (e.g., implementation).

“They worked the process so that they fit in the aspirations and dreams of the people.
That doesn’t often happen. Too often you get to a certain place within the bureaucracy
and then it stops because they say we’re not mandated to go that far, personally,
they came to our Marae, and honoured that Marae and they were culturally sensitive,
culturally appropriate, and so they did all the right things”. (Community leader)

Use of evidence

Terms such as ‘structured’, ‘scientific’, ‘independent’ and ‘evidence-based’ were
used to describe how HIA created or enhanced the legitimacy of having health considerations
included in decision-making.

“… that’s like science. You put it up there for public scrutiny and they can knock it
down if they want to or they can support it. When it’s just your thoughts it’s not
there for public scrutiny in the same sense as what a document like that is… The important
thing is that you’re able to document and provide justification for the methods used
and providing that you can do that, then your findings have some substance” (HIA Working
Group, planner statutory agency)

Other process related factors were identified that are not essential but can enhance
the impact of HIAs. These factors related to which and how stakeholders are involved
in the process.

There are often multiple individuals within the HIA process who are identified as
having important roles in influencing the effectiveness of the HIA such as the right
person at the right level, policy entrepreneur, the doer, decision-makers, community
members, the HIA champion, and the problem maker. The individuals involved in a HIA
have significant influence on both the process and outcomes of an HIA. Involvement
of stakeholders including decision makers, members of potentially affected communities,
and representatives of relevant stakeholder sectors (e.g. health, transport, planning)
in carrying out the HIA was identified as being an important influence on HIA effectiveness.

Capacity and experience

Essential stakeholders are those who have the power to either make or influence decisions.
To ensure the effectiveness of a HIA, we identified two main facets to this:

(i) having the direct involvement of the ‘right people’ and

(ii) ensuring that those people are at the ‘right level’ to be able to act on the
findings of the HIA.

The right people are often at senior management level. They have some power (but not
final decision making power), they understand the system well, often have pre-existing
relationships that they can utilise and are in a position to influence the implementation
of recommendations.

“… one of the really critical things around keeping partnerships together is that
you’ve got to have someone that’s got the delegation to keep it running …[because
a] junior person couldn’t make decisions whereas, [name]and I and [name] can make
decisions that enhances sustainability of it into the future” (HIA Working Group,
Health Sector)

In some case studies understanding the local context involved tactically bypassing
the formal level of decision-making to a certain degree to enhance effectiveness.

“If we had have gone to a general manager and said “Look we want to set up a partnership
[to carry out a HIA]” maybe then they would say “No don’t worry, that’s not core business”.
So we didn’t do it that way. We went through almost the back door and got it…” (decision
maker and HIA commissioner, housing sector)

Effectiveness is also related to the particular team of people brought together, not
just the individual. Often in an effective HIA at least one member of the assessment
team is skilled in engaging people in the process. For example, the lead in one HIA
carefully selected the steering group members, made sure the meetings were well organised
and then rang up stakeholders individually after the meetings to ensure the smooth
running of the project.

“[She] has been quite instrumental in a whole range of different areas. There’s been
one in terms of just being able to build partnerships, get people on the side in her
own quiet way and very skilful… you’ve got to have someone who’s keen on driving it
so that the rest of you either come along or can check in and say okay where are we
at”. (HIA working group, planner, government department)

Key participants can act as HIA champions (advocates for HIA). For example, a senior
manager in a council advocated for a HIA, which contributed to getting buy-in from
the council. In two other HIAs, local councillors who had been involved in the HIA
process went on to advocate for HIAs or to refer to the HIA when engaging in council
business (e.g. at council meetings).

Respondents reported that involving decision-makers had a strong influence on effectiveness.
Direct involvement appeared to be most powerful when the decision-making organisation
was involved in the HIA working group (as opposed to steering group) and involvement
in the assessment and recommendation stages was reported to be particularly important.
Involving decision-makers directly in the process enabled HIA recommendations to be
constructed in ways that would make them easier to adopt.

“So that was actually really good, to have a councillor on there who’ll be able to
say, ‘that word itself [good neighbourliness] will be a block. Don’t lose the concept
but let’s think of a different way of presenting it.’” (HIA Working Group, Planning
department)

Directly involving decision makers in the process was also seen to lead to decision
makers developing a feeling of ownership and responsibility for the HIA findings.

“The benefits …. from my perspective is that by being quite involved in the preparation
of the HIA, or certainly the business end of it from the consultation onwards, I feel
a sense of ownership and obligation to try and keep that going.” (HIA working group,
decision maker, local council)

Relationships/Partnerships

Intersectorial involvement was seen to lead to relationship building between sectors,
and the HIA process was seen to facilitate this. A participant commented how HIA:

“is a legitimising mechanism for intersectorial working… this provided a platform
to put those together in a cohesive way [and provided a] mechanism to legitimise why
some people should be worried about other people’s work” (HIA working group, social
planner)

Intersectorial involvement was also seen to improve the quality of the HIA process
and findings. In describing why the process worked, another stakeholder commented:

“I think it was a good working team so you had a broad range of professions working
together. So you had health professionals, community, engineering and I think we all
learnt from each other. So you had some that would have pie in the sky ideas and others
–you know me – keeps right on, follow the facts step by step, what are you going to
do, how are you going to do it and so I think that bought it together to make that
happen which was good”. (HIA working group, health sector)

Our findings suggest that HIA legitimates, strengthens and increases the credibility
of intersectoral processes and the processes themselves add legitimacy to HIA. Thus
this creates a virtuous circle whereby each event increases the beneficial effect
of the next 25].

Community involvement

Community involvement was also seen to be an important factor influencing effectiveness.
Participants talked about how community involvement influences effectiveness. For
example a participant described how input from the community changed the decision
makers thinking about what the best location for a health service was – going against
standard practice. They then went on to describe how the community input legitimised
the change in decision.

For me, on reflection, it was the best thing that ever happened because [key stakeholder]
actually ended up being told through a process that involved community input that
in fact, we made a decision that this is what the community wants. It’s not what a
[key stakeholder] thinks, it’s not what a health professional thinks what’s going
to be the best.
(decision maker, health services)

Problem makers

Participants can also complicate effectiveness. For example, in one HIA a local councillor
managed to stop the proposal in relation to which the HIA was being conducted. The
other stakeholders in the HIA then re-scoped the HIA to focus on aspects contained
within the original proposal, which could still be influenced.

“There was a huge media beat up and as a [the two main organisations] withdrew from
any future stages of the [name] strategy … but they both said, we’re going to take
the recommendations from the HIA, they will go into council’s mainstream policies
so they will inform – council’s still going to spend money on [name of area] and it’s
not going to be called the [name] strategy…. [lead organisation] said to us that we
will take their recommendations …..“(HIA working group, Health Sector)

Context factors

The institutions within which the stakeholders work and other broader contextual factors
were identified as influencing effectiveness, including:

the planning and decision making context

“There was a real commitment in the organisation to get it right and the organisation
saw it as serious… it formed part of the development application documentation that
needs to be assessed and signed off by local authorities, state authorities and then
regional as well. It had to fit in with the context of regional locality.”
(decision-maker, local council)

broader global context

“The other thing, is again a combination of what we were doing but also the, emerging
national and international focus upon urban design and liveability and sustainability
within cities. That was the context in which the [] Strategy was developed”. (decision-maker,
regional organisation of councils)

unanticipated events and activities that may influence a HIA

“External factors that are out of your control. … So in between our starting and completing
[the HIA], it [the land] was sold and we had to put the brakes on everything at one
stage and that was precarious because it was then that [representative of decision-making
organisation involved in HIA] left the region. We were quite nervous about that ‘cause
it got handed to someone else in her team with less experience … it was an interesting
fight for a while”. (HIA working group, health sector)

Having shared values and goals between participants in the HIA was identified as positively
influencing the perceived success of the HIA. These shared values can occur at a personal
level (e.g. people directly involved in HIA process) and at organisational level (e.g.
between organisations (inter-sectoral working) and between an organisation and the
local community. It can facilitate trust between stakeholders and was seen by some
to have been a powerful motivation for getting people engaged in the project, particularly
where there had been a history of distrust.

“Transparency, accountability, egalitarianism were inherent values there that we spoke
about initially, those generic values to do with HIA but we really worked hard in
trying, putting them into practice” (HIA working group, health sector)

The effectiveness of HIAs is often judged by whether stated goals were met. This can
be problematic when goals have not been made explicit.

“it’s almost like you’re not allowed to sit around this table unless you can tick
all these boxes and show you understand why you’re here because we’ve had people at
the table that haven’t been properly briefed and they’ve come in with a traditional
PPP [public private partnership], … contract management approach, it’s actually created
a bit of conflict and you end up back tracking and it’s not good for progressing the
partnership forward, you actually have to invest too much time on band aiding or sorting
out those issues. I think values, alignment, commitment and understanding of the projects
outcomes not the outputs”. (project proponent)

Lack of clarity or agreement among stakeholders can lead to conflicting views on the
success or effectiveness of the HIA. However having different purposes need not always
be problematic. For example, in one case study one stakeholder focused on HIA capacity
building, whereas another key stakeholder, who was also a decision-maker, wanted to
improve their plan and planning process; yet the difference in purposes was not considered
a problem. In this example although the purposes were different they were not in conflict
with each other.

Cross cutting themes

We also identified some factors that cut across the conceptual framework domains of
context, process and impacts.

Proactive positioning

Respondents reported proactive engagement in the decision making cycle to either influence
the cycle to fit the HIA or being flexible in the HIA process to fit the changing
cycle as a key element of HIA effectiveness. For example, in one case it was recognised
that the HIA was occurring too late in the decision making cycle to influence the
strategy itself, so the team chose to re-scope the HIA to focus on an aspect of implementation
which they could influence and was likely to have a significant impact on the local
community.

“At that stage it almost became derailed because we realised that our screening process
may not have picked up the [timing]. It was after scoping that we actually realised
that the HIA itself needed concentrating on the implementation of the policy [rather]
than the actual decision making process …”
(HIA working group, health sector)

Another example describes how the HIA team pushed for the HIA to be included in the
planning process.

“So we thought, here’s an opportunity. We’ll see if they’ll be interested and will
allow us to work with them to do the HIA … So there was negotiation with them, a lot
of reassurance”. (HIA working group, health sector)

Being in a proactive position is influenced by contextual factors such as organisational
support and culture, existing processes and relationships that may sensitise individuals
and organisations to recognise and act on opportunities to be involved in an HIA.
This proactive positioning suggests that opportunities for HIA are more than just
good timing.

“The importance of being able to be flexible and at the same time then being able to
meet the deadlines. …. The importance of ensuring the decision making was involved
right through the process, the journey and the recommendations at the end and having
ownership of that in effect. Those things were all very key”. (HIA working group,
health sector)

“… where an organisation has taken a proactive lead and have someone inside the organisation
who’s actually running it and doing it and writing it and we’re being brought in to
be a support for the HIA, actually there’s more buy-in and traction. And it has quite
a long-term impact inside the organisation.” (HIA consultant)

Having buy in and feelings of ownership by decision makers was perceived to increase
the likelihood that recommendations were accepted and implemented.

A senior public servant described the actions they took to ensure that HIA was mainstreamed
within the organisation in terms of formalising the organisation’s relationship with
health.

“… when I retire in a couple of years I guess from a succession planning perspective
I wanted to make sure that the partnership was firmly entrenched in our business planning
so that we know that when we start a new urban regeneration project the first tick
off point is, let’s get HIA happening in some form”. (HIA commissioner, housing)

Time and timeliness

Consistent with the HIA literature 16], 26]–28], time, timing and timeliness were recurring themes in the eleven case studies 10] (see Table 3). Specifically the time, timing, and timeliness of the HIAs were often not ideal
but that the process was flexible enough to be adapted to make it work. There was
also no perfect time in the planning or decision-making cycle to carry out a HIA.
In general earlier was seen to be better. Some HIAs were carried out late in the decision
making process and even after decisions had been made but were still able to influence
implementation and were perceived to be effective. Practitioners reported adapting
the timing of the HIA during the process to maximise opportunities to influence decision-making.

“I thought the timing was really good. I thought actually having [the proposal] before
it was drafted and while it was still being written was a much more proactive place
to start from”. (HIA consultant)

“The timing of this one I think was very good, it commenced after we had something
on the table, but not a final proposal that was a done deal.”(decision maker, local
council)

Table 3. Components of time that influence HIA effectiveness

Time was described as a resource: it was needed to carry out the HIA; to train to
do the HIA; to build and maintain relationships; and to deal with changing circumstances.
The value of having organisational support for dedicating specific personnel time
to working on the HIA was emphasised.

“I actually went off work for two weeks solid, I stopped my other role to do it, rather
than doing what I did and trying to doing something else, so there was a real commitment
in the organisation to get it right and the organisation saw it as serious”. (decision
maker, local council)

Factors identified as influencing the timeliness of HIAs ranged from wider drivers
such as current interest in the relationship between the built environment and health
to practical local factors such as the HIA fitting into existing workloads.

“The other thing is again a combination of what we were doing but also the emerging
or at that time – national and international focus upon urban design and liveability
and sustainability within cities. That was coming through the media and so that was
the context on which the Strategy was developed” (HIA working group, Health sector)

“there’s no good or bad time for the HIA …. We’ve already got the base data there
to assist, it may pick up additional information we need to feed into that register;
this list just helps galvanise and then work through it. Generally we’ve had the HIA’s
completed prior to major works in an area so we can then strategically arrange work
around what’s going in”. (HIA working group, engineering)