Lessons about health impact assessment: Learning by Doing

VicHealth Walk to School HIA
VicHealth team presenting on their equity focused health impact assessment

Last week I attended the final day of a Learning by Doing health impact assessment (HIA) training program. Learning by Doing is a structured six-day training program run by the Centre for Health Equity Training, Research and Evaluation (CHETRE), where I work. The training is broken up into distinct stages. People learn about HIA, go away and do the steps they’ve learned about, then come back to reflect and learn about the remaining steps.

The final day is always great because the different groups who have been doing HIAs present their work and their findings. There were five HIAs conducted in this round of Learning by Doing, which involved the South Western Sydney Local Health District, the NSW Department of Family and Community Services, VicHealth, Liverpool City Council, the Think+Do Tank and community representatives.

Lessons

Some of the stand-out lessons from the Learning by Doing sites were:

  • A lot of the value of HIA lies in highlighting and clarifying assumptions made during planning.
  • A planned engagement approach is useful as part of all HIAs.
  • Conceptual learning remains an important outcome of HIAs, in particular learning about health equity.
  • Involving consumers in HIAs has multiple practical benefits, such as identifying alternatives and providing an understanding of  context and history.
  • Scoping remains as critical as always – being rigorous but not biting off more than you can chew (it also reminded me of this paper about scoping in EIA).
  • Not all barriers can be overcome; you need to be realistic about what you can achieve within the limits of an HIA.

More on Learning by Doing

For more on CHETRE’s work on health impact assessment go to HIA Connect. The Learning by Doing approach is described in greater detail in the chapter below:

Harris E, Harris-Roxas B, Harris P, Kemp L. “Learning by Doing”: Building Workforce Capacity to undertake HIA – An Australian case study, in O’Mullane M (ed) Integrating Health Impact Assessment into the Policy Process: Lessons and Experiences from around the World, Oxford University Press: Oxford, 2013, p 99-108. ISBN 9 7801 9963 9960 Google Books link

Health impact assessment needs maturity models

Whenever I used to write anything about health impact assessment I started with “HIA it is a new field”. That’s no longer the case. People have been grappling with how to make HIAs routine for more than twenty years. This has taken different forms. It’s described as institutionalisation, mandating, capacity-building, integration, harmonisation and even theoretical alignment. People have often conflated quite different HIA activities as the same thing,  complicating things. This led to people talking at cross-purposes.

How to make HIA part of routine practice is really none of these things. It’s about how we get HIA to the next level?

The next level?

What do I mean by this? The next level represents deeper embedding in routine practice. A more sophisticated understanding of when HIA can be useful. A large enough body of practitioners with varying levels of experience.

These challenges apply within countries but also globally.

How do we get from where we are to this next level? We have describe what the current state of practice is (this varies). We also have articulate what our desired future state would be. And then we have to describe what steps lie between.

Maturity models can help us.

Maturity models

Maturity models are quality improvement tools that were first used in information technology. ‘Maturity’ referred to the optimisation of processes, including changes from ad-hoc to formalised arrangements and ongoing quality improvement. This involved describing different levels of maturity across several different domains.

The different domains in a maturity model are usually rated for their maturity:

  1. initial – involves individual heroes, is not well documented and hard to replicate
  2. repeatable – processes are well enough described or understood that they can be repeated
  3. defined – the processes are defined and confirmed
  4. managed – the processes are managed in line with agreed metrics
  5. optimising – process management includes ongoing optimisation and improvement.

In some cases a sixth level is added.  This involves embedding capability across all processes.

What would HIA maturity models include?

HIA maturity models would enable us to think about which domains of maturity matter. These could include:

  • organisational capacity
  • workforce
  • leadership
  • resources and tools
  • resource allocation.

I think use of maturity models would enable more sophisticated thinking about capacity building. It would enable discussions to move beyond their historical focus on regulations and workforce. I’ve attempted to pull together a draft HIA maturity model below.

Maturity Model for HIA - Concept

This model isn’t perfect and it won’t be applicable in all settings. It will need to be adapted, changed and maybe even started from scratch. I hope maturity models like it will enable a more nuanced way of thinking about the domains of capacity that are required and to focus activity and investment.

In summary

Maturity models  give systems, organisations and HIA practitioners a better framework for understanding the range of capabilities that we need for HIA to flourish. HIA maturity models would identify:

  • the domains of HIA capability
  • provide a basis for appraising HIA capability, development and performance
  • describe the characteristics of different levels of HIA capability
  • provide a description of what enhanced capability and practice would involve.

I think maturity models represents a promising area of practical and conceptual development for HIA. I’m interested in what you think.

The Impact and Effectiveness of Equity Focused Health Impact Assessment in Health Service Planning

Thesis_Cover

This free ebook looks at the use of equity focused health impact assessment (EFHIA) on health service plans. It examines:

  1. What are the direct and indirect impacts of EFHIAs conducted on health sector plans?
  2. Does EFHIA improve the consideration of equity in the development and implementation of health sector plans?
  3. How does EFHIA improve the consideration of equity in health planning?

Download PDF (3.5 Mb)

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For Whispernet transfer N.B. Costs US $0.99

About the ebook

This ebook describes the use and evolution of health impact assessment (HIA) and EFHIA internationally and in Australia, how it has been used in relation to health service plans, examines its effectiveness and impacts on decision-making and implementation and examines several EFHIAs using case study and interpretive description methodologies.

This research shows that EFHIA has the potential to have both direct and indirect impacts on health service planning. These impacts are influenced by a broad range of factors however. The case studies in this ebook show that engagement with the EFHIA process and the extent to which EFHIA is regarded as a broader learning process are important factors that mediate the extent to which EFHIAs influence subsequent activities.

This research suggests that it is not possible to adequately describe the full range of impacts of EFHIA on decision-making and implementation without looking at perceptions about EFHIA’s effectiveness, in particular the perceptions of those involved in the EFHIA and those responsible for acting on its recommendations. These perceptions change over time, suggesting that future research on the effectiveness of HIA should look at the mechanisms by which this change occurs.

The ebook makes two theoretical contributions in the form of (i) a typology for HIAs and (ii) a conceptual framework for evaluating the impact and effectiveness of HIAs. This conceptual framework is tested for its applicability and refined.

The ebook and the accompanying publications were written to fulfil the requirements for a Doctor of Philosophy in Public Health at the University of New South Wales.

Health Impact Assessment: The state of the art

 

Several International Association for Impact Assessment Health Section members and I have written a paper in the latest issue of Impact Assessment and Project Appraisal on Health Impact Assessment: The state of the art. It’s part of a special issue on the state of the art in impact assessment that was edited by Alan Bond and Jenny Pope. Most of the papers are excellent reading for anyone interested in impact assessment.

Harris-Roxas B, Viliani F, Bond A, Cave B, Divall M, Furu P, Harris P, Soeberg M, Wernham A, Winkler M.  Health Impact Assessment: The state of the art, Impact Assessment and Project Appraisal, eFirst.
doi:10.1080/14615517.2012.666035

The paper is available for free to IAIA members, just log into the IAIA website and follow the IAPA link. If you have difficulty accessing the paper please contact me.