This document provides background on a presentation about the current state of health impact assessment (HIA). It discusses the history and evolution of HIA from three origins - environmental health, social view of health, and health equity. Key events and documents that shaped the development of HIA are presented, such as the Gothenburg Consensus Paper which identified important values like democracy, equity, and sustainable development. The document also discusses current approaches to HIA internationally and notes challenges like scoping impacts, strength of evidence used, and appropriate resourcing of HIAs.

2. Background
• This presentation is based on a paper that is being prepared for
Impact Assessment and Project Appraisal by members of the
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International Association for Impact Assessment’s Health
Section.
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• The paper presents an overview of HIA activity internationally
and future directions for the field.
• It is an update of the last IAIA effort to describe the state of the
It is an update of the last IAIA effort to describe the state of the
impact assessment field in Vanclay and Bronstein’s 1995 book on
Environmental and Social Impact Assessment.
Environmental and Social Impact Assessment.
• I’d like to acknowledge the contributions of the co‐authors so far.
• I’d also like your feedback on the issues presented.
Vanclay F, Bronstein D (Eds.) (1995) Environmental and Social Impact Assessment, Wiley:
Chichester.

3. History
• The evolution of HIA can be viewed as a little different from EIA
• EIA has been strongly focused on major project assessment
in many jurisdictions
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• In recent decades it has expanded to encompass other
strategic assessment processes such as strategic
strategic assessment processes such as strategic
environmental assessment (SEA)
• There’s a lot HIA can learn from other forms of impact
assessment, but HIA can potentially inform other impact
assessment processes too, e.g. practice norms about public
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dissemination of completed reports, etc

4. History
• HIA can be seen as originating from three separate areas of
activity
• Environmental health
• Social view of health
• Health equity
• Each bring with them their own disciplinary beliefs, values,
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support base and baggage
Harris‐Roxas B, Harris E (2011) Differing Forms, Differing Purposes: A Typology of Health
Impact Assessment, Environmental Impact Assessment Review, 31(4):396‐403.
doi:10.1016/j.eiar.2010.03.003

5. History
• Environmental Health
• Mostly grew out of work on major project assessment in
developing countries
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• Has often focused on building health into EIA processes
• Relies on scientific and predictive evidence
• Often has a biomedical or toxicological focus, appropriately
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given the context and history of its use
• Uses methodologies such as prospective health risk
Uses methodologies such as prospective health risk
assessment

6. History
• Social View of Health
• Grew out of an increasing recognition of the social
determinants of health
• Has often focused on policies and strategies rather than at
the project level
the project level
• Sees HIA as applying to other sectors, not necessarily health
• Involves working intersectorally/with other parts of govt
• Defines health and acceptable evidence more broadly
Defines health and acceptable evidence more broadly
• Sees the process of the HIA itself as important
• Uses methodologies such as quantitative modelling and
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qualitative research

7. History
• Health Equity
• Grew out of the need for interventions that can address
health inequalities in policy development and planning, i.e.
q p y p p g,
before inequalities come about
• Often conflated with social health but it is possible to look at
Often conflated with social health, but it is possible to look at
social health without considering differential impacts
• Forces a greater discussion of values
• Tends to focus more on issues of differential health impacts
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• Uses varies methodologies but participation is often valued
highly as evidence within the HIA
highly as evidence within the HIA

8. HIA
Health Equity
Social View of Health
Social View of Health
Environmental Health
Regulatory Environmental Impact Assessment
Environmental Disasters
1950s 1960s 1970s 1980s 1990s 2000s
1956 Clean Air Act (UK) 1962 Silent Spring 1972 Lake Pedder Dam 1980 The Black Report 1990 Concepts & 2004 Equity Focused HIA
controversy (UK)
( ) Principles of Equity
l f Framework k
(Australia) in Health (Australia)
1959 Minamata Bay 1969 Santa Barbara
1980 International
(Japan) Channel (USA) 1990 Environmental
1972 The Indian Wildlife Association for 2005 Health included in
Protection Act (UK)
(Protection) Act Impact Assessment IFC Performance
1969 US National formed
Environmental Standards
1992 Asian Development
1974 Lalonde Report
Policy Act (USA) Bank HIA
(Canada) 1984 Bhopal (India) 2005 Guide to HIA in the
Guidelines
Oil and Gas Sector
1969 Cuyahoga River
1974 Environmental 1986 Ottawa Charter
Fire (USA) 1994 Framework for
Protection (Impact
( p 2007 1st Asia‐Pacific HIA
Environmental and
En ironmental and
of Proposals) Act 1986 Chernobyl Conference
Health IA
(Australia) (Ukraine) (Australia)
(Australia)
1978 Seveso (Italy) 2007 HIA’s use included
1989 Exxon Valdez Oil 1997 Jakarta
in Thailand’s
Spill (USA)
Spill (USA) Declaration
1978 L
Love Canal (USA)
C l (USA) Constitution
C i i
1998 Independent
1978 WHO Seminar on 2008 WHO Commission
Inquiry into
Environmental on the Social
Inequalities in
Health Impact Determinants of
Health (UK)
Assessment
Assessment Health: Closing the
Health: Closing the
(Greece) Gap in a
1998 Merseyside Generation
Guidelines for HIA
Source: Harris‐Roxas B, Harris E. Differing forms, 1978 Declaration of
2009 Montara West
differing purposes: A typology of health impact Alma Ata
1998 The Solid Facts Atlas Oil Spill
, p
assessment, Environmental Impact Assessment (Australia)
Review, 31(4): 396‐403. 1979 Three Mile Island
doi:10.1016/j.eiar.2010.03.003 (USA) 1999 Gothenburg
2010Marmot Review
Consensus Paper
on HIA

9. History
• The Gothenburg Consensus Paper was important in the
development of the HIA field. It identified the values participants
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saw as governing HIA’s use:
• Democracy
• Equity
• Sustainable Development
• Ethical Use of Evidence
Ethical Use of Evidence
• These values reflect the context in which the Consensus Paper
was developed by European HIA practitioners
• The ways and extent to which these values inform actual HIA
The ways and extent to which these values inform actual HIA
practice warrants attention as well
ECHP (1999) Gothenburg Consensus Paper on Health Impact Assessment: Main concepts
and suggested approach, European Centre for Health Policy, WHO Regional Office for
Europe. http://www.euro.who.int/document/PAE/Gothenburgpaper.pdf

10. International Perspectives
International Perspectives
• There are currently several approaches to legislating and
institutionalising HIA’s use:
’
• Requiring health be considered as party of EIAs or broader
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impact assessment (many WPRO countries’ EIA legislation; IFC Performance Standards;
Equator Principles; EIA legislation in other regions)
• Requiring stand‐alone HIAs on a type/category of proposals
(Thai National Health Act; Lao PDR; Tasmania, Australia)
• Giving health authorities the right to conduct HIAs where
Giving health authorities the right to conduct HIAs where
they deem it necessary or appropriate (Victoria, Australia)
• L i l ti th i ht f
Legislating the right for communities to request HIAs be
iti t t HIA b
conducted or to be involved in them (Thai Constitution)
• Regulations or policies that support HIA’s use but do not
require it (many local governments and authorities in Europe; New South Wales, Australia; New
Zealand)

11. International Perspectives
International Perspectives
• The following approaches are not exactly requirements for HIA
but may be related or lead to HIA’s use
’
• Requiring a health review or screening of all government
q g g g
policies (Netherlands during the national government’s screening program; Quebec Provincial
Government; NSW Aboriginal health Impact Statement)
• The discretionary use of non‐HIA processes to look at health
issues (South Australia’s Health Lens)
• Capacity has been a critical factor in determining the extent to
which these legislative mechanisms have been actually
which these legislative mechanisms have been actually
implemented
•M
Many HIAs are conducted outside legislative requirements,
HIA d t d t id l i l ti i t
though the extent varies markedly depending on context

12. Current HIA Practice
Current HIA Practice
• HIA’s use has grown rapidly
• Scoping is critical
• Poor HIAs are too often the result of poor scoping/Terms of
Poor HIAs are too often the result of poor scoping/Terms of
Reference
• There needs to be a more rigorous approach to scoping to
ensure that a more comprehensive potential health impacts
are at least considered
• At the moment we often lapse into stereotypical approaches
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to identifying potential impacts

13. Current HIA Practice
Current HIA Practice
• Strength of evidence used to make predictions
• We can be better at transparently stating the degree of
uncertainty
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• We also need to be realistic that predicting many important
impacts will always rely on weaker or more speculative
impacts will always rely on weaker or more speculative
evidence

14. Current HIA Practice
Current HIA Practice
• The resourcing of HIA – too much or too little?
• HIA requires resources and needs to be responsive to
decision‐making needs but also still be detailed and credible
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• But how much is the right amount?
• It has been suggested that within the context of integrated
IAs/ESHIAs that between 10%‐20% of the overall IA budget
should be spent on health
(Birley M, IAIA Conference 2006 and 2007)
•I ’ l
It’s less clear what the appropriate level of funding is for HIAs
l h h i l l f f di i f HIA
of policies
Harris‐Roxas B, Harris P, Harris E, Kemp L (2011) A Rapid Equity Focused Health Impact
Assessment of a Policy Implementation Plan: An Australian case study and impact
evaluation, International Journal for Equity in Health, 10(6), doi:10.1186/1475‐9276‐10‐6.

15. Current HIA Practice
Current HIA Practice
• A more nuanced approach to the consideration of alternatives
• At the moment most HIAs focus minimally on alternatives, and
those that do are limited to
• Siting alternatives (known as “end of pipe”, area or size
alternatives) or
alternatives) or
• Technological alternatives
• More attention needs to be paid to
• Knowledge alternatives (issue definition alternatives)
Knowledge alternatives (issue definition alternatives)
• Institutional alternatives (ways of doing business)
• Goal alternatives (what you’re trying to achieve)
Sukkumnoed D, et al (2007) HIA Training Manual: A learning tool for healthy communities
and society in Thailand, Southeast Asia, and beyond, Health Systems Research Institute:
Bangkok.

16. Current HIA Practice
Current HIA Practice
• There is an emphasis on community consultation and
researching stakeholder views
• There’s less clarity about how this should be reconciled with
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competing or contradictory forms of evidence
• A greater understanding of and consensus about the type of
A greater understanding of and consensus about the type of
baseline measurements and monitoring that are required

17. Opportunities and Threats
Opportunities and Threats
• The opportunities and threats to HIA and its use are often the
same
• Better integration of health and HIA into other assessment
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processes
• At the moment health is often limited to health risk
At the moment health is often limited to health risk
assessment that are conducted as stand‐alone assessments
within larger assessment processes
within larger assessment processes

18. Opportunities and Threats
Opportunities and Threats
• Capacity
• We need to recognise that there are currently few incentives
for practitioners to build others’ capacity
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• The focus at the moment is often on introductory training
but the need is greatest for experienced HIA practitioners,
but the need is greatest for experienced HIA practitioners
i.e. people who have done several HIAs, people who can
commission and review them, etc
commission and review them etc

19. Opportunities and Threats
Opportunities and Threats
• A more nuanced understanding of what we’re trying to learn
through HIA
• Technical learning, which involves searching for technical
g, g
solutions to fixed policy objectives
• Conceptual learning which involves redefining policy goals
Conceptual learning, which involves redefining policy goals,
problem definitions and strategies
• Social learning, which emphasises dialogue and increased
interaction between policy actors
• Because of HIA’s rather diverse origins we can’t assume
there’s a shared understanding of what we’re seeking to
learn through doing HIAs in all contexts
Glasbergen P (1999) Learning to Manage the Environment in Democracy and the
Environment: Problems and Prospects (Eds Lafferty W and Meadowcroft J), Edward Elgar:
Cheltenham, p 175‐193.

20. Opportunities and Threats
Opportunities and Threats
• Recognising that there is a diversity of HIA practice that allows it
to be responsive but challenges efforts to standardise practice
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• Who is HIA for? Who does it? When?
• The answers to these questions will be different in different
contexts
• Ensuring recommendations are made, acted upon and
monitored
• Independence: realistic or desirable? How can we ensure
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independence? Should we?
• HIA reporting could also be improved
HIA reporting could also be improved

21. Where to next?
Where to next?
• We’ve actually come a long way as a field in relatively short time
• In 1995 Birley and Peralta wrote that:
“At present HIA is a blunt tool with the rudiments of an accepted
methodology”
• This is no longer the case. There is greater consensus about the
procedural elements of HIA (e.g. screening, scoping, etc) and
procedural elements of HIA (e g screening scoping etc) and
well as when it is most useful
Briley M, Peralta G (1995) Health Impact Assessment of Development Projects in
Environmental and Social Impact Assessment (Eds Vanclay F and Bronstein D), Wiley:
Chichester, p 153‐170.

22. Where to next?
Where to next?
• Potential activity:
• Industry‐specific HIA guidance, eg mining, wind power, etc
(
(some already exists)
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• Regional guidance, e.g. for WPRO region
• Better guidance and professional development specifically
focused on scoping
• Improved methods for economic appraisal of health impacts

23. Where to next?
Where to next?
• There is need for a new international consensus on HIA
• Revisiting the values that govern HIA’s use to ensure they’re
relevant to the current diversity of HIA practice
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• This is no easy task but will be necessary to ensure that HIA
practice is not fractured and continues to benefit from being
practice is not fractured and continues to benefit from being
used in a variety of forms and settings
Krieger G, Utzinger J, Winkler M, Divall M, Phillips S, Balge M, Singer B. Barbarians at the
gate: storming the Gothenburg consensus, The Lancet, 375(9732): 2129‐2131, 2010. doi:
10.1016/S0140‐6736(10)60591‐0
Vohra S, Cave B, Viliani F, Harris‐Roxas BF, Bhatia R. New international consensus on health
impact assessment, The Lancet, 376(9751):1464‐1465, 2010. doi:10.1016/S0140‐
6736(10)61991‐5

24. These slides are available at
www.slideshare.net/benharrisroxas
b.harris‐roxas@unsw.edu.au
@hiablog
healthimpactassessment.blogspot.com
linkedin.com/in/benharrisroxas