HIA's essential elements

Four essential elements of HIA were identified (table 1). First, HIA rests on assessing a draft policy proposal, based on knowledge of the effects of past decisions and events, to predict the potential health and equity impacts of that policy and influence policy making. One participant characterised this aspect of HIA as ‘applied epidemiology’ and this predictive aspect of HIA was identified as powerful, valuable and important. Second, participants emphasised how HIA is a structured, stepwise process that enabled dialogue to occur between sectors and stakeholders. One participant explained how HIAs structured ‘created shared meaning’ and another commented how: … in public policy when we talk about using HIA it is a dialogue process…the dialogue with the other government department.

Third, making recommendations was described as essential because it is the point at which HIA becomes relevant (or not) and absorbed (or not) into policy decision-making.

Fourth, the positioning of HIA in the policy process is flexible: in some instances, HIA can be rational and undertaken outside the policy process whereas in others it can occur as part of the incremental policy process. This relationship was explained as follows: … So that makes it difficult if you are trying to define a common approach to HIA. That when you reach point X, you do an HIA and you don't get past that point unless you have done it. You just can't do it that way. We need to be much more flexible than that. And we are not going to change that.

HPP's essential elements

Four essential elements of HPP became apparent (table 1). First, HPP's conceptual foundation is the broad definition of health as well being rather than disease. In this way, HPP was connected to social, economic and environmental issues in public policy making, and differentiated from ‘health policy’ concerns with hospital or health care services. Correspondingly, some felt that an explicit discussion of the word ‘health’ is not required. This avoidance of health ‘imperialism’, particularly in initial engagement with other sectors, was seen as a hallmark of HPP engagement: ...we need to ... not impose our social model of health but just initiate discussion

Second, while avoiding health imperialism, the purpose of HPP was to design policy to improve people's health and reduce health inequities.

Third, HPP rests on intersectoral collaboration. This was originally coded as intersectoral action. During analysis, however, it became clear that collaboration with public health was essential. Participants explained how, despite avoiding health imperialism, particularly in early engagement, public health brought to policy development the necessary expertise linking policies to population health.

Fourth, HPP was characterised as involving systematic collaboration from the inception to the end of policy development. In this way, HPP was seen as the ideal type of policy engagement (subject to contingent influences).

Most participants used the terms HPP and HiAP interchangeably. Therefore, the remainder of this paper uses HPP to cover both concepts.

The relationship between HIA and HPP

HIA was described as one important structured method for HPP. On the one hand, HIA offers HPP a technical prediction about the potential population health consequences of public policy proposals. On the other, HIA offers HPP a process for structured dialogue thereby making transparent (often complex) consideration of policy problems, proposed solutions and their potential population health impact.

HPP was identified as bigger in scope than HIA, including negotiation, advocacy, lobbying and the use of evidence in policy. HIA and HPP were also recognised as mutually supportive—HPP provided a rationale for HIA and HIA a mechanism for HPP—but also able to be practised separately. However, participants felt HPP was less clearly defined than HIA which had led HIA, mistakenly, to become the de-facto method for HPP. As a result, participants felt too much expectation had been placed on HIA to deliver We expect too much from it…it is unrealistic to expect…that you can slip in, do an HIA, and all your recommendations will be implemented and then you can go away…That's just not how life works at all.

The relationship was also characterised as straightforward, where HIA was seen as a process to influence policy to include health considerations, and not straightforward because of the values and systemic or institutional constraints influencing both HPP and HIA. These constraints are identified in the following sections.

Public policy

Both HIA and HPP presuppose the existence of public policy. For example … we need to start thinking a bit more about this public policy process and what we're actually trying to get at.

Five essential features of public policy became apparent as influences on the practice of both HIA and HPP (table 1).

First, public policy was emphasised as a process. When discussing policy making, some participants explained public policy as linear, following various basic stages. Others observed policy as iterative and incremental, with no common pathway. Importantly, the two are not mutually exclusive as the finding that there is common pathway to policy does not necessarily negate policy occurring in (non-linear) stages. However, the policy pathway was, as a result of being incremental or ‘skipping stages’, characterised as making it ‘not clear’ where HIA is best undertaken. Participants also suggested that in practice HIA risks coming in too late in the policy-making cycle. The structured process of HIA was, however, recognised as flexible enough to fit alongside policy making.

Second, economic growth and productivity, not public health, was recognised as driving public policy development. The inclusion of analyses of economic costs was emphasised as an important, often missing, element of both HIA and HPP. Importantly, however, the inequitable effects of economically focused policy were felt by some as the reason they engaged in HIA and HPP.

Third, participants recognised how public policy is made at different institutional levels, from government ‘green’ and ‘white’ papers, and ultimately legislation, to local implementation plans. Further, both policies and plans were recognised as essential elements of public policy, where the latter develop the actions of the former. Participants also felt that the systematic practice of HIA and HPP requires the inclusion of both policies and plans at multiple levels. Local-level policy development was often framed as easier to influence than that of the central government.

Fourth, the public policy making environment was recognised as incorporating a great number of competing demands—including other regulated impact assessments—and struggles based on power and politics. Adding health, and the complexity accompanying a broad definition of health, was suggested as risking adding another complexity to already complex policy environments.

Fifth, sector-specific agendas were explained as essential in shaping the way sectors approach policy making and how they see the place of health as supporting, or not, their specific ways of developing policy. For example, one participant recalled how, in his work with other government departments, health outcomes were seen as secondary objectives that required support from the health sector if they were to be adopted: What they saw was that health was a secondary benefit from the work they did...And we got a lot of that. You know education similarly, ‘Our aim is to get people educated for economic reasons…as long as we hit our primary objectives, health is a good secondary objective, and we will have a look at that, and if you help us as a health department.’ So there are issues around agendas… about health imperialism. We shouldn't feel ashamed of it,health we have to recognise that other people won't see it as legitimate…for them it is actually, ‘why can't we (eg, education) come and tell you (health) what you should do to help us.’

Other influences on HIA and HPP

Seven influences on HIA and HPP were identified as contingencies, without the consideration of which the previously identified necessary elements of HIA and HPP practice are, in reality, insufficient.

First, HPP and HIA require collaborative engagement, and demonstrated investment, from public health. For example, the participant from land-use planning identified public health involvement as the main factor in successful HIAs she had been involved in; Typically it was where there was strong Public Health... where Public Health would have a good relationship with Planning and actually, show Planning that they could bring something to the table.

Public health, specifically population health, was described as the institutional resource best able to develop intersectoral collaboration: ...we in the population health arena seem to me to have a very special place because we do look, we do see where the gap does lie. And nowhere else in the health system has that sort of mandate…, and nor does anyone else really have the skill to look outside.

However, participants felt that Public Health—notably ‘those of us who are persuaded by all this’ –was yet to create a mandate within the health sector, and by extension broader government, to legitimise a role in intersectoral public policy development.

Second, government structures were identified as critical. Linked to the central role of agendas in policy making, government progresses specific agendas through siloed structures, each with different ways of developing and implementing policy. This was identified as making intersectoral collaboration difficult (particularly at central government levels). The whole of government targets were identified as facilitating working across siloes. These enable people to start thinking outside traditional lines of accountability. Participants suggested HIA had provided a process for doing this.

Third, people's characteristics and competencies were seen as important contingencies. Interest and involvement in either HIA or HPP was seen as stemming from values of social justice, equity and improving population health. However, these values were discussed as not being uniformly held among public health practitioners and organisations. Being open to new ideas and ways of working were felt to be important. However, over-reliance on entrepreneurial individuals rather than building a critical mass of skilled practitioners was identified as a problematic characteristic of the HIA field to date. Skills were mainly discussed in terms of public health collaboration in intersectoral policy development and creating the necessary relationships for this to occur.

Fourth, the evidence base was identified as an important contingent influence. Participants described both HIA and HPP practice as being at the mercy of the available evidence. Complexities in capturing the links between policy and health, and especially well being, outcomes were noted as problematic issues that influenced the practice of HIA. The relevance of health data on disease or mortality was questioned because non-health sectors often require cost rather than health outcome data. Despite this, systematically using and articulating health evidence to inform policy was seen as being valued by intersectoral partners, although using this evidence to inform HIAs was noted as requiring support from public health practitioners.

Fifth, the community was described as the point where the effects of policy decisions are felt. HIA was thereby singled out as enabling communities to have a democratic voice-within policy development. Notably, participants suggested that community voice is absent from HPP. In addition, participants cautioned that managing community expectations of what HIA can and cannot deliver was important.

Sixth, societal values were identified as influential on both HIA and HPP. This was couched in terms of societal values being oriented towards individuals rather than communities or populations. Several participants pointed out an important long-term goal of their work in HIA and HPP was to change societal values to become more equitable. For example, I think the real trick is... moving people from the... the individual, you know, ‘everybody has responsibility for their own health kind of thing’ to there are social reasons why we have these health outcomes and that, I think, is a really very broad battle that has to happen that's way beyond healthy Public Policy, or Health Impact Assessment, but those are pieces that can help move in that direction.

Finally, the time required to influence meaningful policy change was highlighted as an often unrecognised contingency by HIA and HPP advocates and practitioners

This research empirically supports and adds depth to the, mostly non-empirical, HIA and HPP literature. The essential elements of HIA suggested here are similar to those identified in established definitions of HIA.10 These findings, however, add to these definitions that HIA is essentially flexible in the way it is applied to the public policy process.31 ,32 Turning to HPP, this study supports the essence of HPP as being dependent on a broad definition of health18 ,33 and intersectoral collaboration.34 ,35 However, the institutional mandate for public health to play a coordinating and supporting role in the intersectoral use of HIA for HPP is emphasised but currently underdeveloped.

The finding that HIA and HPP presuppose the existence of ‘public-policy’ returns to the original healthy public policy literature.36 Conceptually, the importance of public policy processes in relation to HIA for HPP has been recognised31 ,37 but not yet widely adopted.7 Notably, Thailand, arguably the most successful country at embedding HIA for HPP, has based this activity on established theoretical conceptualisations of public policy.38

The findings also help clarify the currently uncertain relationship between HIA and HPP7 ,20 The two are different and mutually reinforcing although each can, and does exist, without the other. Most importantly, HIA was understood as one important mechanism to enable the systematic consideration of health in public policy18 while being part of a broader suite of HPP activities.33

Separating essential HIA and HPP elements from contingent influences helps practitioners and researchers identify what can be directly controlled or changed to improve practice, and what else needs to be planned for as contingencies largely outside the control of HIA or HPP practitioners.31 Methodologically, this is not a question of homogenising or flattening difference.26 Rather, this aids practice and future research to identify, empirically and substantively, whether essential properties exist or not, and how these exert influence on practice or not.

The qualitative design was used to investigate the depth of the participants’ experience. This study design has some limitations. Participants were few and largely HIA advocates or using HIA in their work. Given the research question, which explicitly aims to understand HIA's fit with healthy public policy, this purposive sampling was required. However, future research should investigate the relationship from the perspective of people working in HPP and public policy who may not include HIA in their work. Future research could use, verify and extend these findings as factors influencing the design, achievements and struggles of the many programmes and projects currently being undertaken internationally to progress health and equity within public policy.