HEALTH IMPACT ASSESSMENT IN THE NEW ZEALAND POLICY CONTEXT.

• Author: Signal, Louise

Abstract

Assessing the health impact of policy outside the health sector is a key part of public health policy making. Policy makers use health impact assessment to improve, promote and protect the health of populations. This paper defines health impact assessment and provides justification for the use of formal health impact assessment tools. The New Zealand policy-making process and the mechanisms currently used within the public sector to assess health impact in New Zealand are discussed. Examples in the public domain from recent public policy making are used to illustrate the discussion. The paper then examines the opportunities that exist for public sector public health policy advisers assessing the health impact of policy in other sectors, given that policy can be a fiercely contested domain, and considers why the generic mechanisms are insufficient to achieve optimal influence. The supports needed for the successful application of formal tools, and the obstacles that exist, are analysed.

INTRODUCTION(3)

Health impact assessment (HIA) has been defined as "a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population" (European Centre for Health Policy 1999). We view it as a means to ensure healthy public policy -- that is, as a means of putting health on the agenda of policy makers across government, assisting them to be aware of the health consequences of their decisions.

There is support for HIA internationally and in New Zealand. There has been increasing international interest (Lewis 2000, Scottish Needs Assessment Programme 2000). The Commission of the European Union has included HIA in its work (Commission of the European Communities 1995). In 1998, the UK Government proposed that "major new government policies should be assessed for their impact on health" (Secretary of State for Health 1998).

An early attempt to use HIA in New Zealand occurred at the Public Health Commission with the production of A Guide to Health Impact Assessment (Public Health Commission 1995). This guide for public health services focused on HIA only in relation to environmental issues. Subsequently, during consultation on the strategic direction for public health in 1996/97, it was proposed by the Ministry of Health that HIA be implemented at a high level across government, possibly at the Cabinet level in a similar way to Treasury compliance requirements. It was suggested that a formal HIA tool should be developed in cooperation with other sectors (Ministry of Health 1997b). Strong support was received for this proposal.

More recently, the National Health Committee (NHC) has proposed the adoption of HIA (Lewis 2000). This recommendation has emerged from the NHC's work on inequalities in health. The Committee has recognised the very real potential HIA has for addressing the health impacts of the determinants of health.

Further, the recently released draft New Zealand Health Strategy acknowledges the need to address the determinants of health and the important role the health sector has to play in intersectoral action to promote health (Minister of Health 2000). It argues that this role includes "assessing relevant public policies for their impact on health and health inequalities". The first goal is "a healthy social environment". The first objective under this goal is "to assess all public policies for their impact on health and health inequalities" (Minister of Health 2000:10). Clearly, there is support for HIA in New Zealand, but what does it actually involve and why is it needed?

WHAT IS HIA?

HIA provides formal tools to enable us to identify both direct and indirect impacts on health. It is a structured way of bringing together evaluation, partnership working, public consultation, and available evidence for more explicit decision making (Lock 2000:13961397). It has the potential to examine the direct impacts on health of policy in other policy arenas, and to look at the way policy in other arenas impacts on the determinants of health, and subsequently on health itself.

What would be the benefits of systematically undertaking HIA using formal tools? Formal tools provide the means to do systematic analysis of the health impacts of policy in other policy arenas. They provide a means of strengthening what is currently done, doing it more effectively and more frequently.

The benefits, and the formal tools used, can best be illustrated by an example. Let us consider the impact of immigration policy on health, and particularly on the incidence of tuberculosis in New Zealand. The number of notified cases of tuberculosis in New Zealand has been declining for several decades, and reached a low point in 1988 when 295 cases were notified. Since then the annual number of cases has increased. Around 300-400 cases are reported each year. The rate of tuberculosis in New Zealand is almost double that in Australia. The proportion of New Zealand cases born overseas (such as in Malaysia, Hong Kong, Korea, Vietnam, Samoa and Tonga) has been steadily increasing, from 50% in 1993 to 66% in 1997 (Ministry of Health 1997a). Guidelines for Tuberculosis Control in New Zealand (Ministry of Health 1996) states that "immigration and visitation have been important factors contributing to the increase in tuberculosis in New Zealand since 1988" (p.6).

While acknowledging the range of recommendations that were made to the Government by the Ministry of Health and the New Zealand Immigration Service, and subsequently accepted, a group of clinicians were still highly critical of what they perceived as inadequacies in immigration policy, and the health response, in relation to tuberculosis. These were detailed in a paper published last year in the New Zealand Medical Journal. Their criticisms ranged from the length of time students or visitors from high-tuberculosis incidence countries should be allowed to stay in New Zealand before being screened for tuberculosis (they recommended a reduction in the length of time from two years to six months) to improvements in New Zealand's commitment to tuberculosis control in Pacific countries (Harrison et al. 1999).

From the perspective of other sectors, students, visitors and migrants bring needed skills, capital and revenue to New Zealand. It is perceived that, if New Zealand places higher health requirements on these groups than is the practice in other countries, these potential immigrants will go elsewhere -- to the detriment of New Zealand's economy and social diversity. New Zealand also has humanitarian responsibilities to displaced persons who may seek refuge here and to those who may seek asylum. The interface between immigration policy and health is clearly a contested domain that is bedevilled by ideology, opinion and differing world views. The generic mechanisms that have been used by the Ministry of Health, which are employed by every government department to influence other sectors' policies (in this instance, immigration policy), are clearly perceived as inadequate by key players in the health sector.

Perhaps immigration policy would benefit from the application of formal health impact assessment tools -- screening, (4) The Crime Prevention Unit is now part of the Ministry of Justice. scoping, health impact analysis, consideration of alternative options, consultation with those likely to be affected, and action on the results. It would pass an initial screening that would demonstrate the significant relationship between immigration policy and health. Policies subject to screening may be identified as a result of a checklist developed for use by policy advisers in all sectors, or as a result of "case finding" based on accepted criteria (Scottish Needs Assessment Programme 2000). Further information could be gathered as part of scoping, which employs key informants to identify the direct and indirect health effects of the policy, the populations affected, and the methods that should be used for the HIA process.

Health impact analysis in this situation would need to be multi-disciplinary, and use a combination of methodologies, particularly epidemiological and economic modelling. It would assess the impact of immigration policies on the prevalence and incidence of diseases in New Zealand, and the health service consequences that are affected by immigration policy. Using such a model, it should be possible to test the impact of alternative options to maximise the positive and to minimise the negative impacts. The report that arose from this work would be the basis for public consultation to make sure that those who are likely to be...