Thinking about HIA effectiveness

Washington MonumentI’m in Washington D.C. for a meeting on evaluating health impact assessment, which has been organised by the Health Impact Project at the Pew Charitable Trusts.

As part of my preparation for the meeting I’ve pulled together some of my ideas into a document, based mainly on my involvement in the Effectiveness of Health Impact Assessments in Australia and New Zealand ARC-funded project.

I’d be interested in any feedback. In particular I’d appreciate any responses to what I think remains unknown/future directions for HIA evaluation research:

  • How does HIA change perceptions at individual and organisational levels and how can we better account for this through research design?
  • How can we better evaluate learning that can occur through HIAs, at individual and organisational levels?
    • Technical
    • Conceptual
    • Social (Glasbergen, 1999)
  • How can we account for different forms of bias in evaluations of HIA?
    • Framing bias
    • Confirmation bias
    • Hindsight bias
    • Creeping determinism
    • Narrative fallacy (Harris-Roxas et al 2014)
  • How can we develop a more nuanced approach to scoping HIAs to consider the determinants of health inequities, as distinct from the determinants of health?

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Source: Harris and Harris-Roxas 2010

“What is clear here is that impact assessment is beginning to be seen not just as a tool for informing and influencing decision-makers, but as a process which changes the views and attitudes of stakeholders who engage with the process such that their own attitudes and practices change outside of the immediate decision making context. That is, the influence of impact assessment processes may extend well beyond the narrow decision window in which they operate. There is also recognition that such learning operates on an institutional and social level as well as on an individual level.” Bond & Pope (2012:4)


Bond A, Pope J (2012) The State of the Art of Impact Assessment in 2012,  Impact Assessment and Project Appraisal, 30(1): 1-4. Download PDF

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, 175-193.

Harris E, Harris-Roxas B (2010) Health in All Policies: A pathway for thinking about our broader societal goals, Public Health Bulletin South Australia, 7(2): 43-46.

Harris-Roxas B, Haigh F, Travaglia J, Kemp L (2014) Evaluating the impact of equity focused health impact assessment on health service planning: Three case studies, BMC Health Services Research, 14(371), doi:10.1186/1472-6963-14-371.

Communicating about equity in HIA

There’s a useful new resource from The Society of Practitioners of Health Impact Assessment about discussing health equity in HIAs:

The SOPHIA Equity Working Group

Communicating about Equity in HIA: A Guide for Practitioners.

HIAs provide an opportunity to advance equity. Practitioners often struggle with how to effectively communicate about equity in HIA, and strategically communicate about this core value of HIA. An effective approach to communication is fundamental to ensuring that HIAs can impact policies and support change.

This guide intends to aid HIA practitioners in their efforts to communicate about equity as an essential step towards advancing equity.

Link to document

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


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.

WHO Urban HEART Consultation Day 3

IMG_4166I’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 3 of the Consultation, there are also posts on Day 1 and Day 2.

Workshop 3: Review of Urban HEART guidance

There was a widespread view that the current Urban HEART guidance works quite well but that there are a few areas where it might be enhanced. There was discussion about the selection of interventions and responses being difficult in practice, and that it involves considerable negotiation. There wasn’t agreement about the best ways to reflect this in the guidance but it was a recurrent theme, and one that’s familiar in the context of HIA and negotiating recommendations.

Community participation is another aspect of Urban HEART that has been difficult to provide guidance on. Participatory rapid assessments, health assemblies, surveys, workshops, and the use of mobile and electronic engagement tools were all discussed as ways to involve communities in Urban HEART processes, though these were all recognised as having limitations.

There was quite a lot of discussion about the extent to which HIA might be integrated into Urban HEART, though it was agreed that Urban HEART and HIA are complementary rather than being processes that could be integrated. This is because Urban HEART helps to identify needs and areas for action at the city level, whereas HIA is most useful where there is a proposal or a limited set of options to assess. So whilst there are procedural similarities they serve quite different purposes and integrating them might complicate things rather than helping. The diagram below from the Urban HEART User Guide shows how WHO conceptualises Urban HEART’s role in local planning cycles. Some related procedures like multi-criteria decision analysis and equity lenses were also discussed, and how they might be integrated into Urban HEART.

Screen Shot 2013-11-08 at 11.36.05 am

An important issue that was discussed was that we need to focus on enhancing the equity focus of Urban HEART rather than simply improving the technical aspects of the process. The value of Urban HEART is its equity focus rather than its health focus, and we need to prioritise that in any revisions. This is something I hadn’t really considered before and I think it poses a challenge to the HIA practitioners: beware focusing on improving technical aspects of the assessment process at the expense of an equity focus. Technically perfect assessments won’t necessarily result in inequities being better addressed.

The need to demonstrate economic effectiveness/cost-benefit was also discussed. This is familiar territory for HIA practitioners! I confess that I have mixed feelings about this. Whilst I can see that there are benefits to even limited economic approaches to describing the economic benefits of HIA or Urban HEART (willingness to pay analyses, estimated savings based on case studies, etc), ultimately Urban HEART and HIA are about informing and improving planning and decision-making. They’re not readily comparable to other health interventions because they’re fundamentally different types of interventions.

The need for an online guide, repository and clearinghouse for evidence was discussed. We’re very fortunate in HIA to have the HIA Gateway. The consensus was that something similar is required for Urban HEART.

City case presentations

Madeleine Ntetani-Nkoussou discussed the use of Urban HEART in Brazzaville, Congo. There’s a number of issues in Brazzaville associated with informal settlement/slums and rapid urbanisation. The physical and service infrastructure has struggled to keep pace. Potable water access and access to water sealed toilets remain big issues, as is food security. urban HEART helped the city identify the four arrondissement that required greater activity, in particular around the provision of health services and prevention activities.

Plenary discussion: Next steps

One issue that was raised is whether there a need or mechanism to involve state and national governments in Urban HEART? Though this approach would have relevance to them, a big part of the appeal of Urban HEART is the clarity of the indicators and its applicability at the city level.

The distinction between Urban HEART as an indicator/diagnostic tool and a framework to guide implementation came up a few times. It’s intended to be both, but there’s a tension, which most HIA practitioners would have encountered as well.

There was quite wide-ranging and detailed discussion about approaches to building capacity for Urban HEART, which I won’t describe in detail here because I’m not able to do justice to the range of issues discussed. Some of the broad topics touched on included:

  • capacity building
  • sharing best practice, particularly in the form of brief case studies focused on key learning
  • building Urban HEART into WHO and country-level work plans
  • linking to professional groups/associations
  • ensuring the health sector comes along the journey and that Urban HEART doesn’t become the sole responsibility of cities/other sectors
  • how often does Urban HEART need to be revisited/redone
  • how can we make Urban HEART sell itself, i.e. so it doesn’t need much ongoing support
  • compendiums of best practice and then thinking how some of these best practice cases might be synthesised
  • how to advance an equity agenda in settings where it’s not on the political agenda

These issues are all eerily familiar to people who’ve worked on HIA! It was an excellent Consultation with lots of food for thought that also highlighted how well-designed Urban HEART is and how much work has gone into its development. I plan to do another post in a few days that brings together some of the critical points and what the implications might be for HIA.

WHO Urban HEART Consultation Day 2

KobeI’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 2 of the Consultation, there are also posts on Day 1 and Day 3.

Workshop 1: Review of Urban HEART concepts

The first workshop focused on factors affecting health equity that might be missing from or not sufficiently emphasised in Urban HEART. These include things like gender, food and nutrition, emergency preparedness, conflict and security, universal health coverage and environmental sustainability.

The issue of within-neighbourhood disaggregation was discussed, particularly in terms of age and gender, but there was a broad recognition that this data simply isn’t available for most indicators and that this may add a layer complexity to an already imposing process. There was also a recognition that many indicators of health equity might not be sensitive enough, or may reflect structural or systemic inequalities, to change at the local or city level. These issues will be very familiar to those who have looked at equity and vulnerability within impact assessments.

There was quite a bit of discussion about the degree to which Urban HEART needs to be regarded as a standardised, readily-comprehensible approach or something that can be adapted to local needs. This is a debate I’ve encountered several times in relation to HIA and the answer seems to lie somewhere between those two extremes.

City case presentations

A presentation from Dr Oyelaran-Oyeyinka from UN-HABITAT emphasised the important role cities play as the engine rooms of economic development, though the challenge is to ensure that’s inclusive development. Internationally the urban-rural divide is diminishing but the rich-poor divide is increasing.

Kelly Murphy from St Michael’s Hospital in Toronto presented on her work adapting Urban HEART for use in developed countries. The City of Toronto has adopted Urban HEART as a mechanism to guide funding of Neighbourhood Improvement Areas and Issue to 2020.

The difficulties encountered in Toronto include:

  • working together (team changes, maintaining relationships, timelines, expectations)
  • Urban HEART being easy to use but not easy to produce (the process is clear but the sources of data is not, potential misinterpretation of results, e.g. stigmatising areas or only focusing in “red” areas when gains could be made in “yellow” ones).

The facilitating factors in Toronto incude:

  • WHO Brand associated with Urban HEART lent it credibility
  • trusted convenor
  • established relationships
  • credible technical expertise (epidemiologist with recognised track record and relationships)
  • senior champions (administrative rather than elected representatives)
  • City’s willingness to innovate
  • lead partner providing secretariat support (so the process “belonged” to someone)
  • community involvement
  • specific funding from CIHR to get the ball rolling, though the City of Toronto has now adopted this as a process within its “Wellbeing Toronto” monitoring and reporting activities

Kelly spoke about the need to talk about equity for all sectors, as opposed to health equity, and responsiveness to policy processes. Urban HEART was regarded as a clear tool that “made sense”. Despite being a developed city, Toronto found that Urban HEART was a useful approach and that the domains of the tool were still relevant.

Jose Velandia Rodriguez from Bogota, Columbia also spoke about his experience using Urban HEART in Bosa, a region within Bogota.

Workshop 2: Review of Urban HEART indicators

Most cities that have used Urban HEART have had to adapt the core indicators to some extent, or only use some of them. Most cities have also used secondary or suggested indicators as well, rather than solely the core indicators. The evaluations of city case studies so far have emphasised the need to integrate environmental and qualitative indicators/information to a greater extent.

There was a wide-ranging discussion of how and whether universal health coverage should be reflected in the Urban HEART indicators. There was a broad agreement that there should be at least one amongst the core indicator set that deals with universal health coverage, given the global focus on it, but it’s hard to identify what the key domains of UHC are. It’s generally regarded as having three dimensions – access to health services, utilisation of health services and financing of health services. There was recognition across the workshops that whilst UHC financing clearly has an impact, it often lies beyond the scope of local government to influence. They have a greater role in access and utilisation, often by providing co-funding or premises and in some cases payments to cover the direct health care costs of the poor.

The discussion on this was wide-ranging and quiet comprehensive. Rather than recapping it here I’ll just note that WHO is currently developing a UHC indicator set, which will be drawn on in selecting the UHC indicators to be included in Urban HEART. The indicators will need to focus on access and quality and have some sensitivity to vulnerability and equity at the local level. In general, geographic distribution of services is an available indicator in many settings, but beyond that it’s hard to say what will be available. Health care-related impoverishment (where people are pushed into greater poverty by healthcare costs) and catastrophic health expenditure were identified as important measures with clear equity implications, though it is unclear about how these can be turned into indicators reliably or meaningfully.

There was also discussion about how to incorporate ageing-related indicators into Urban Heart, though the consensus was that it may be more important to ensure there is disaggregation of other indicators by age rather than adding new indicators. It may be useful to refer people to WHO’s guidance on age-friendly cities where appropriate.

Emergency management indicators have already been committed to in some form, following WHO discussions with other UN agencies. These might include existence of emergency standard operating procedure plans in local government agencies. Other indicators might include prevalence of disaster-resistant buildings, e.g. earthquake-resistant buildings, people trained in emergency response, presence of local emergency response groups/networks, etc.

Qualitative data may help to fill in gaps and supplement other indicators. There was some discussion about how to integrate and present qualitative data in Urban HEART.

A bigger issue is that there is a need to ensure Urban HEART has as few possible indicators as possible in order to enhance usability, and that the indicators included are all equity-sensitive and available. They also essentially need to be geo-coded, at least at a neighbourhood level, and very few indicators are in *any* setting. Addressing this will be no easy task.


WHO Urban HEART Consultation Day 1

IMG_4183I’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on some of the issues discussed on Day 1, with some of my thoughts and reflections scattered throughout. There are also posts on Day 2 and Day 3.

Urban HEART grew out of the Commission on the Social Determinants of Health‘s work and dates back to 2007. Early activity on piloting and developing a tool were led by a few countries, notably Iran. The final report from the CSDOH gave further impetus and led to more piloting of Urban HEART in more cities. After piloting Urban HEART was extensively reviewed and Version 1 was published in 2010.

Urban HEART is conceptualised by WHO as a tool for assessment and response to health equity issues at the city level. Urban HEART was designed to meet four criteria:

  • ease of use
  • comprehensive and inclusive
  • feasible and sustainable
  • links evidence to action

It’s a stepwise process with a lot of similarities to HIA. In contrast to HIA it doesn’t need a proposal (even a general one or options) to assess. Rather it allows municipalities to identify issues for action and responses at the city level, and in that way it’s more like a needs assessment or planning activity. It’s useful where some willingness to act on health already exists, so Healthy Cities is a useful basis for action. Higher-order support is always required (which may be less true for HIA?).

Data that informs Urban HEART is almost always spread across agencies – no single one holds or reports on even the core indicators. This means multiple permissions and interagency liaison is often required, which reiterates the need for higher-order permission and negotiation at the earliest stages. Whilst this is undoubtedly desirable for HIAs as well it hasn’t always been possible in my experience and HIAs often fly under the radar, at least in the early stages. I’m not sure that would be possible for Urban HEART but I’m not sure that’s a bad thing. The under-the-radar HIAs I’ve been involved in have often encountered resistance when their recommendations are presented. A clear, unambiguous mandate and imprimatur as a basis for proceeding isn’t a bad thing.

A survey of Consultation participants that was conducted in advance found that most participants thought Urban HEART works well overall, is easy to use and successfully links evidence to action, but is less successful at being comprehensive and organisationally sustainable.

Case studies from the City of Paranaque in the PhilippinesTehran in Iran and Indore in India provided a range of useful, practical lessons on the use of Urban HEART (and they were quite inspirational). The Inore case in particular modified the indicators in a way to suit the local context, in their case by ensuring that the indicators were all meaningful and comprehensible to anyone, from residents to national bureaucrats. The case studies also highlighted the need for Urban HEART to not be a one-off activity but as an activity that needs to be revisited/undertaken semi-regularly.

How should we stratify/disaggregate equity analyses?

One issue that was identified at the Consultation is whether looking at geography and sub-municipal spatial areas as the unit of analysis always appropriate? For example might gender, poverty or age at the city level be a more appropriate way of analysing health equity issues? This is a recognised tension because all health equity analyses should use gender and SES for stratification but cities are often focused on neighbourhoods and a spatial approach. In many ways it points to a bigger, perhaps more overtly political discussion about what do we mean by health equity?

Scaling up

It was noted that approaches scaling up Urban HEART might not be the same in all cases because it’s so linked to the scope and role of government, so this will vary markedly. Encouraging progress has been made internationally, as the map below illustrates.

urban heart world map

Questions arising from Day 1

  • How can we promote Urban HEART better?
  • How can we involve NGOs or the private sector? Should we?

My general reflections

  1. An issue I have encountered is the limited availability of *any* health indicators at the city/local government level, let alone sub-city levels, given that cities can be quite small in scale with limited resources in Federalist systems.
  2. The health sector will always need to be involved in the use of Urban HEART in some capacity because they hold the data, or some of the data, but they needn’t be a roadblock. A pragmatic approach to getting the best available data but to focus on response strategies and interventions helps.
  3. In some ways the most useful thing that health systems can do is to regularly report on a broad range of health indicators at city and sub-city (disaggregated) levels, so cities can pick up Urban HEART and other related approaches and run with them.


The application of Equator Principles in high-income OECD countries

Map of the Ichthys LNG Project Area in North West Australia
Map of the Ichthys LNG Project Area in North West Australia

There’s a very interesting post by Mehrdad Nazari about the use of the Equator Principles and related performance standards in an Australian setting:

The Equator Principles website highlights that “Designated Countries [such as Australia and other high income OECD countries] are those countries deemed to have robust environmental and social governance, legislation systems and institutional capacity designed to protect their people and the natural environment”. The EPIII also notes that for “Projects located in Designated Countries, the Assessment process evaluates compliance with relevant host country laws, regulations and permits that pertain to environmental and social issues”. In the preceding paragraph, the EPIII highlights that for “Projects located in Non-Designated Countries, the Assessment process evaluates compliance with the then applicable IFC Performance Standards on Environmental and Social Sustainability (Performance Standards) and the World Bank Group Environmental, Health and Safety Guidelines (EHS Guidelines) (Exhibit III).”

Despite the proponents in the Ichthys LNG Project reportedly used the EPIII performance standards in an Australian context. Read the post in full here.

Speaking in a purely personal capacity I’d like to see more use of the Equator Principles in developed countries. They’re rigorous and well-understood internationally, and can help to allay international investor concerns and facilitate due diligence on a project. An excellent point is made in the comments for Mehrdad’s piece:

Although Australia is a developed country, projects like this are usually situated in remote areas which have many of the same characteristics as developing nations: delicate & untouched environment, indigenous traditional landowners, etc. Local laws regulate these issues but, by hedging its bets, the bank does not have to due diligence local law to the same extent – and the syndicate’s lawyers don’t have to convince 41 credit committees.

Thanks to Martin Birley for alerting me to the piece, cross-posted at the HIA Blog.

Using social media for messaging about healthy eating and active living

I was fortunate to have the opportunity to do a session on “using social media for messaging about healthy eating and active living” with Dr Becky Freeman from the University of Sydney recently. I’ve attached the slides from the session below, which probably won’t adequately capture what was covered but may provide some background if you have any questions. If you do, please email.

Does health impact assessment protect health? Is that the right question?

There’s a thought-provoking piece at ABC Environment on Does environmental impact assessment protect the environment? The piece quotes several well-known Australian EIA academics about how well EIA in Australia is performing in terms of environmental protection.

There’s no consensus in the piece about whether EIA is successfully protecting the environment or not, though some different ways of thinking about it are discussed. I think that’s because the article dances around the core issue: what is the purpose of EIA? This may seem axiomatic and uncontested but I wonder if it’s an under-examined difference between the goals and purpose of impact assessments.

In a sense we’re lucky in the HIA field. The yoke of regulatory requirement and government mandate hasn’t weighed us down too much… yet. Practice is still evolving and hasn’t been circumscribed by regulations and legal challenge to the same extent as EIA. Because of this, my impression is that there’s more acceptance that an HIA will probably have a limited impacts on health outcomes in itself. The stated goals of HIA are to protect health, promote health and to reduce health inequalities (and possibly to improve governance and public decision-making, as well as learning). HIA seeks to influence decision-making and implementation in order to influence a range of determinants of health, which in turn will impact on health outcomes, as shown below:

Diagram - HIAs Influence

This is an idealised representation of an HIA’s influence. Other assessment processes, organisational considerations and even broader social conditions will play much larger roles. In fact the process depicted is never linear either. Health outcomes and determinants are constantly changing, and decisions are constantly revisited. The delay between an activity and eventual health outcomes can sometimes stretch to decades. At each step there are a multitude of other factors that exert influence, apart from the HIA.

Though HIA’s goal is to protect health, like EIA’s is to protect the environment, the practical purpose of an HIA is to change decisions and implementation – the first step in the process depicted above. We should think about the purpose of EIA the same way. It’s not an environmental intervention, it’s a decision-making intervention/ Burdening it with expectations of environmental protection isn’t realistic.

If we do acknowledge that it will be difficult if not impossible for an HIA to demonstrate its role in changing health outcomes, we should redouble our efforts to prove its effectiveness in influencing decisions and implementation. I made a related argument in a recent article:

In some ways the issue of effectiveness may have less currency in relation to other forms of IA [than HIA]. Impact assessment, in particular environmental impact assessment, is used in some form in almost every country. Its use is common, accepted, well understood and not usually actively compared to other interventions or activities. This is not necessarily true for health impact assessment though because of the resource constraints and associated health disciplinary and epistemological concerns… if HIA’s use is to continue to be supported in increasingly resource-constrained health systems that demand evidence of the comparative effectiveness of interventions.

The right question is not whether HIA changes health outcomes. Instead it’s does HIA change decisions, implementation and ways of working?