Environmental Impact Assessment Review 25 (2005) 772–782

www.elsevier.com/locate/eiar

Equity-focused health impact assessment: A tool to

assist policy makers in addressing health inequalities

Sarah Simpson a,*, Mary Mahoney b, Elizabeth Harris b,

Rosemary Aldrich c, Jenny Stewart-Williams d

aCentre for Health Equity Training Research and Evaluation, School of Public Health and Community Medicine,

University of NSW, AustraliabHealth Impact Assessment Research Unit, Faculty of Health and Behavioural Sciences, Deakin University,

Victoria, AustraliacUniversity of Newcastle, NSW, Australia

dNewcastle Institute of Public Health, University of Newcastle, NSW, Australia

Available online 15 August 2005

Abstract

In Australasia (Australia and New Zealand) the use of health impact assessment (HIA) as a tool

for improved policy development is comparatively new. The public health workforce do not

routinely assess the potential health and equity impacts of proposed policies or programs. The

Australasian Collaboration for Health Equity Impact Assessment was funded to develop a strategic

framework for equity-focused HIA (EFHIA) with the intent of strengthening the ways in which

equity is addressed in each step of HIA. The collaboration developed a draft framework for EFHIA

that mirrored, but modified the commonly accepted steps of HIA; tested the draft framework in six

different health service delivery settings; analysed the feedback about application of the draft EFHIA

framework and modified it accordingly. The strategic framework shows promise in providing a

systematic process for identifying potential differential health impacts and assessing the extent to

which these are avoidable and unfair. This paper presents the EFHIA framework and discusses some

of the issues that arose in the case study sites undertaking equity-focused HIA.

D 2005 Elsevier Inc. All rights reserved.

Keywords: Health impact assessment; Equity

0195-9255/$ -

doi:10.1016/j.e

* Correspond

E-mail add

see front matter D 2005 Elsevier Inc. All rights reserved.

iar.2005.07.010

ing author. Tel.: +61 2 9385 0420; fax: +61 2 9385 0140.

ress: sarah.simpson@unsw.edu.au (S. Simpson).

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782 773

1. Introduction

Australia and New Zealand have been international leaders in the development of

health impact assessment (HIA) as part of environmental health frameworks. In these

countries health impacts have traditionally been considered as part of environmental

impact assessment (EIA) (Harris and Simpson, 2003b; Mahoney and Durham, 2002).

Recently the two countries have become increasingly interested in exploring the use of

HIA for policy development (National Public Health Partnership, 2003; Mahoney and

Durham, 2002; Public Health Advisory Committee, 2004). However, the use of HIA as a

tool for policy development is still comparatively new within public health, and public

health workers do not routinely assess the potential health and equity impacts of proposed

policies, programs or projects (hereafter referred to as proposals).

Health impact assessment uses a structured, stepwise impact assessment process to

assess the potential health impacts of proposed policies (for example a new taxation

policy) (European Centre for Health Policy, 1999; Mahoney and Morgan, 2001). Other

characteristics integral to this application of HIA include,

! use of a broad definition of health—to include assessments of hazards and risk as well

as ways in which health could be promoted and the social forces that impact negatively

on health reduced (Harris and Simpson, 2003b);

! assessment of the health impacts on populations directly and indirectly affected;

! assessment of the distribution of these impacts across different population groups

(Simpson et al., 2004).

Health impact assessment provides a structured process for improving a proposal by

providing decision-makers with information on potential health impacts and recommenda-

tions for improving the proposal, thereby contributing to improved policy development. In

addition, while equity is considered a core value of HIA (Ritsatakis et al., 2002; Douglas

and Scott-Samuel, 2001; Douglas et al., 2001; European Centre for Health Policy, 1999;

Health Development Agency, 2001; Kemm, 2001), it is also important to make explicit the

consideration of equity, so that HIA can illuminate the equity impacts of a proposal.

During the mid 1990s key commentators on HIA advocated its use to assess the

potential equity impacts of proposals (particularly policy proposals)—this was referred to

as health inequalities impact assessment (Acheson et al., 1998; Acheson, 2000; World

Health Organisation, 1997). There have been some debate about the need for a yet another

separate form of impact assessment. Some practitioners of HIA have indicated a

preference for equity in every HIA rather than health inequalities impact assessment

(Douglas and Scott-Samuel, 2001; Ritsatakis et al., 2002). There is agreement among

practitioners that the role of HIA, as well as being population focused, is to identify any

differential impacts that may arise for specific groups likely to be affected by the proposal

(European Centre for Health Policy, 1999; Douglas et al., 2001; Kemm, 2001; Ritsatakis et

al., 2002). Examples of tools and guidance that have been developed to facilitate an

equity-focus within HIA and in public health practice include the Bro Taf Health

Inequalities Impact Assessment tool (National Public Health Service for Wales, 2003;

Welsh Health Impact Assessment Support Unit, 2004), the Equity Audit (Association of

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782774

Public Health Observatories, 2003; Hamer et al., 2003) and the Equity Gauge (Global

Equity Gauge Alliance, 2003; Ntuli et al., 2003).

However experience of HIA in the Australasian context together with a review of the

published literature and of practice of HIA in other contexts indicate that addressing equity

in HIA is currently an aspiration rather than a reality (Harris-Roxas et al., 2004; Ritsatakis

et al., 2002). Specific findings were that:

! equity is not effectively addressed in other forms of impact assessment and issues of

avoidability and fairness are rarely examined;

! there is often an uncritical assumption that increased community participation will in

itself ensure an equity perspective;

! there is a lack of structured guidance or tools to assist practitioners to ensure bequity in

every HIAQ;! assessment stops at identifying differential impacts and fails to move to determining

avoidability, fairness and ways to address inequities (Harris-Roxas et al., 2004).

This debate is not unique to HIA. It is occurring elsewhere in the impact assessment

literature. Connelly and Richardson (2005) recently questioned the assumption that the

process of deliberation in Strategic Environmental Assessments (SEA) would result in

sustainable and equitable outcomes for all. They advocated the use of environmental

justice as a structured process during SEA in order to make the different and hard trade-

offs explicit thereby giving some guidance on how sustainability might be achieved.

Based on the belief that the consideration of equity needed to be made explicit in HIA,

and encouraged by the growing interest in the broader application of HIA in Australasia, in

2002 a collaboration of three universities proposed the development of a strategic

framework for health inequalities impact assessment. The partners in the collaboration

were the Institute of Public Health at Newcastle University (NSW), Deakin University

(Victoria) and the Centre for Health Equity Training Research and Evaluation at the

University of New South Wales. The proposal was accepted and funded by the Australian

Government Department of Health and Ageing (DOHA) and the framework was

subsequently renamed equity-focused HIA (EFHIA). The intention in developing the

framework was not to develop yet another form of HIA but to produce more explicit

guidance for practitioners on how they could systematically address equity within the

existing process of HIA. This paper will present the development of the EFHIA framework

developed and discuss some of the issues that arose in case studies of its use.

2. Defining equity and equity-focused health impact assessment

An equity approach recognises that not everyone has the same level of health or level of

resources to deal with their health problems. It may therefore be important to deal with

people differently in order to work towards equal outcomes, where:

. . .the aim of policy for equity and health is. . .to reduce or eliminate those [health

differences], which result from factors which are considered to be both avoidable

and unfair (Whitehead, 1990).

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782 775

Equity-focused decisions are based on the values and assumptions of the decision-

makers. It is therefore important that these values and assumptions are made explicit and

that it is recognised that there may be competing values and assumptions that will make

the decision contested (Harris and Simpson, 2003a).

Equity-focused HIA uses health impact assessment methodology in a structured way to

explore the potential differential impacts of a proposal on the health of specific groups

within a population and to assess if these differential impacts are inequitable.

Equity-focused HIA:

! Identifies the distribution of health impacts across the population.

! Considers if the identified potential health impacts are shared unequally across the

population (e.g. some groups may potentially be more adversely or more positively

affected than others).

! Assesses whether these potential differential health impacts are avoidable and unfair—

that is, inequitable.

! Reduces the potential for these differential impacts to become health inequities by using

the findings from the EFHIA to amend, ameliorate and improve the proposed policy,

program or project (ideally before it is implemented).

3. Development of the EFHIA framework

The Australasian Collaboration for Health Equity Impact Assessment (ACHEIA) was

formed to provide guidance to the EFHIA project. It included the six investigators; the

project officer; international advisers from university and government sectors in the areas

of equity, policy development, impact assessment and HIA; the case study partners from

the EFHIA sites; organisational nominees (e.g. DOHA); and indigenous consultants from

Australia and New Zealand. A full list of the members of ACHEIA is available from the

project website (ACHEIA, 2005).

The process for developing and testing of the EFHIA framework included:

1. Developing a draft framework for equity-focused HIA that adapted the commonly

accepted steps of HIA—screening, scoping, identification and assessment/appraisal of

impacts, negotiation, development of recommendations and evaluation (West Midlands

Directors of Public Health Group, 2000; Scott-Samuel et al., 1998).

2. Developing a manual outlining the draft framework to assist the case study sites.

3. Testing the EFHIA framework in six case study sites in a range of health settings (listed

in Table 1). An EFHIA was undertaken with guidance from one of the investigators at

each of these sites, which offered a range of health settings.

4. Undertaking a systematic review of the literature to identify other models for

incorporating equity considerations into HIA, and to determine the extent to which

equity considerations were incorporated in reported HIAs (Harris-Roxas et al., 2004).

5. Holding a 2 day international capacity building meeting to showcase the draft EFHIA

framework. This meeting included a 1 day training program on applying the

framework.

Table 1

The six EFHIA case study sites

1. New Zealand Ministry of Health. EFHIA of Health Eating Action. Policy, a policy which was written with

specific reference to Maori health.

2. Royal Australasian College of Physicians. EFHIA of Support Scheme for Rural Specialists, a continuing

education and professional development program for specialists in rural Australia using videoconferencing as a

delivery mechanism.

3. National Health and Medical Research Council. EFHIA of a consumer brochure and booklet to accompany the

councils Dietary Guidelines for Older Australians. The aim of the publications was to provide information

about diet and nutrient intake to independent healthy older Australians.

4. John Hunter Hospital. EFHIA of existing outpatient Cardiac Rehabilitation Program, which aimed to optimize

the recovery of patients following an acute cardiac event and to reduce the risk of further cardiac events.

5. Australian Capital Territory Health Promotion Board. EFHIA of the annual Community Funding Program of

grants and/or sponsorships.

6. EFHIA of South Australian Breastfeeding Action Plan 2004–2006 where the EFHIA focused on assessing the

major components of a plan to promote breastfeeding in families and community settings.

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782776

6. Analysing feedback from the sites and the workshop and using this analysis to modify

the EFHIA framework.

4. The framework

4.1. Screening with an equity-focus

The first step in EFHIA is screening in order to determine whether a HIA is actually

required. The equity dimension of screening in EFHIA considers whether the potential

health impacts are likely to be differentially distributed by factors such as socioeconomic

status, ethnicity, gender, geography and if these differential impacts are bunfairQ and

bavoidableQ—that is binequitableQ (Mahoney et al., 2004).

Beginning with an equity-focus requires practitioners to look beyond the health

impacts for the overall population to systematic health differences in sub-groups of

the population and groups who are not specifically included in the proposal. This

approach is not dissimilar to that proposed in the Bro Taf guidance and Welsh

Guidance on HIA where a range of potentially bvulnerableQ population groups are

identified for practitioners to consider during the screening step (Welsh Health

Impact Assessment Support Unit, 2004; National Public Health Service for Wales,

2003; Fig. 1).

Experience at the six case study sites during the screening step of EFHIA showed

the importance of investing time in defining why an equity-focused HIA has been

chosen and to develop a shared understanding of equity. It is also important that the

equity-rationale be made explicit in the screening report. Some found it difficult to

acknowledge that well-intentioned proposals could have unintended and unanticipated

consequences that could be judged inequitable. There was a strong temptation to revise

the proposal at the screening and scoping steps as potential equity impacts are

identified.

SCREENING

Determining the suitability of the policy or practice for an EFHIAand the feasibility of undertaking it. This step includes consideration of:

• the nature of policy, planning or service decision multiplied by the potential for population impact,

• a preliminary assessment to determine the possible • populations affected and the potential equity dimensions • identification of appropriate stakeholders

SCOPING

Setting the scope of the EFHIA, including: • establishing terms of reference (including indigenous aspects) • clarifying dimensions of equity (access, resources, outcomes) • agreeing definitions such as search terms, elements of • SEP/SES • brainstorming for likely or possible impacts of the policy • identifying outcome measures and consideration of how these could be

used for monitoring, and • planning for the EFHIA e.g. timing, management, reporting and

accountability aspects.

ASSESSMENT OF IMPACTS

RECOMMENDATIONS

Weighting and synthesis of evidence and consideration of equity impacts in this setting at this time (such as the nature of impact versus the likelihood of impacts

occurring)

Strategies for monitoring uptake and impact of EFHIA recommendations and systems for evaluating outcomes

Critically appraise literature and other evidence

IMPACTIDENTIFICATION

Review by colleagues, experts/stakeholders as appropriate

Produce a statement of potential impacts on policy on equity

To recommend changes based on the identified likely equity impacts and links to health

Detailed analysis of policy or practice to include: • Identification of policy context • Identification of target population(s) • Data collection on relevant population groups or sub-populations (included

and excluded) • Identification of policy or practice variable(s) of interest

Steps include:

Search literature for evidence of relationship between

populations group, SEP & variable of interest

Consultation with stakeholders, target population, key informants on the

relationship between the variable of interest, the potential or actual impacts,

differential impacts and population group(s)

MONITORING & EVALUATION

Fig. 1. The EFHIA framework.

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782 777

4.2. Scoping with an equity-focus

The purpose of scoping is to set parameters for the assessment. If the equity dimension

is to be covered this must include defining bequityQ outcomes to be expected (to reduce the

gap in health between rich and poor, to reduce the social gradient in health across all

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782778

groups or to improve the health of those with the poorest health). It is also necessary to

agree search terms for the literature review e.g. health inequalities, disparities, inequity,

socioeconomic position and so on. Further one has to negotiate what will count as

bevidenceQ and how it will be weighted, especially in situations where there is no clear

equity-related evidence (Mahoney et al., 2004).

Having a deliberate equity-focus in the scoping step is critical because it drives the

range and types of information collected. The framework provides guidance on how to

identify potential sources of equity-related evidence and suggests search terms and

strategies that are outside of the traditional approach (National Health and Medical

Research Council, 2003). A deliberate equity-focus also allows for an explicit discussion

of equity-related values, of the assessors’ assumptions and of the wider context in which

the EFHIA is being undertaken.

The case study sites found difficulty in ensuring that those who are most marginalised,

had opportunity to make an input to the scoping step. This difficulty was compounded by

the ethical point that involvement in scoping offers no clear or immediate benefit to these

people. They found it was important to move beyond seeing btarget groupsQ, such as

women or youth, as homogenous and to identify potential inequity within these groups.

Further problems were that equity issues were not reflected in much of the published

literature and that traditional search strategies often failed to find relevant evidence. The

assessors then had to decide on how they would deal with disagreements as to how the

evidence that was found should be valued and to decide what to do when the evidence was

limited or conflicting.

4.3. Identification of impacts with an equity-focus

The purpose of this step is to collect information and identify potential health impacts.

An equity-focus at the stage of identifying impacts involves the collection of information

from different sources and profiling of relevant communities and groups within the

population. In order to do this information must be collected from a wide range of sources to

identify potential health and equity impacts. Particular attention must be paid to differential

distribution of potential health impacts as well as their nature, magnitude and likelihood in

order to assess whether these differential impacts are inequitable. This information is then

used to produce a profile describing health inequalities between identified population

groups such as socio-economic, ethnic and gender groups (Mahoney et al., 2004).

Several of the case study sites found difficulty in obtaining information for profiling

because existing sources had not broken down the data into the agreed population groups

or conceptualised health inequalities in the same way as the EFHIA. For example,

available sources may only record differences between groups by place of residence and

have no breakdown by other characteristics such as age, income or ethnicity. Significant

inequalities may therefore be concealed.

4.4. Assessment with an equity-focus

The purpose of the assessment step is to assess the information collected during the

identification of impacts step and establish the nature (positive, negative, neutral or

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782 779

unknown), severity and likelihood of the identified potential health impatcs. The equity

dimensions of the assessment step during EFHIA requires the bringing together of

disparate information to measure differences, to assess the fairness and avoidability of

these differences, to identify divergence and convergence between different sources and to

weight the impacts for equity (Mahoney et al., 2004).

The case study sites found the assessment step challenging because of the limited

guidance available about what to do when the different sources of information (for

example dexpertT and dlayT information) did not converge and how the assessors should

interpret these different sources. When this happened the agreed definition of equity and

objectives for the EFHIA (developed during scoping) became critical. Assessors needed

to discuss and clarify values and assumptions. They further needed to cope with

situations in which no consensus could be found or situations in which unexpected

impacts became apparent.

4.5. Making recommendations with an equity-focus

The purpose of this step is to develop recommendations that are linked to the agreed

bequity-focusQ or the objectives of the EFHIA. The recommendations have to be based on

the findings of the assessment and must be feasible for adoption by decision-makers

(Mahoney et al., 2004).

The EFHIA case study sites found that it was sometimes necessary to make a

recommendation that favoured one group over another. For example one might recommend

redistribution of resources to benefit those groups most likely to experience inequalities and

this was often seen as difficult. Those doing the EFHIA felt they needed further skills to

move beyond the usual description of inequalities to recommending actions to address them.

5. Discussion

Feedback from the case study sites and from the international capacity building meeting

indicated that equity-focused HIA was considered to be a useful tool for systematically

incorporating equity into HIA. Not enough time has yet passed to determine the extent to

which recommendations made through the EFHIA process have been acted upon by

decision-makers.

While the framework enables explicit consideration of equity at each step of HIA, it

places heavy demands of time and other resources. One has to decide when an EFHIA is

more appropriate than an HIA. Some sites found that just undertaking the screening step

was useful because it prompted decision-makers to think differently. Developing tools

for rapid screening of proposals for unintended equity implications may provide bearlywinsQ and result in proposals, which give more weight to an equity-focus. It is also

hoped that experience of EFHIA may encourage decision-makers to consider equity

earlier in the policy development or planning process so that the EFHIA is not needed at

a later stage.

One of the greatest challenges faced by the case study sites was synthesising

conflicting evidence from different sources (scientific literature, document analysis,

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782780

focus groups, etc). While an approach to this has been developed in the EFHIA

framework (Mahoney, 2004) this needs to be further refined. Where evidence is lacking

or divergent the EFHIA process must be transparent. It may be necessary to make

qualified impact statements such as bIf the evidence from the scientific literature is to be

valued more highly than evidence from other sources, then the conclusion is. . .on the

other hand if evidence from focus groups is preferred, then the conclusion is. . .Q. Therole of the EFHIA assessors however is not to force consensus (Connelly and

Richardson, 2005) or remove the need for judgement by decision-makers (Kemm, 2003).

The EFHIA report should make the rationale for prioritising the evidence clear,

including how it was prioritised and any dtrade-offsT transparent. For example, valuing the

information from stakeholders more than information from the published literature may

mean that the equity objective of the proposal is not realised. Information may be

prioritised on the basis of salience, acceptability and appropriateness to the decision-

makers and key stakeholders (Petticrew and Roberts, 2003). Decision-making is

influenced as much by politics as by the bevidenceQ.Workforce capacity and skills were highlighted at the international meeting. If

EFHIA is to become part of regular public health practice and policy development then

HIA practitioners need to increase their skills in making bequity-focusedQ decisions and

developing practical strategies to help decision-makers to improve their proposals.

Meeting participants felt that the framework brought together two very complex ideas,

equity and HIA, and the complexity is compounded by combining them. Practitioners

have long recognised the need to move from describing inequities to recommending

action to reduce them. However even the most committed practitioners find this

difficult to do.

6. Conclusion

As with all HIA, it will be important to evaluate the impact and outcomes of the

actual EFHIAs undertaken to date. The EFHIA shows promise but by itself does not

reduce health inequity. It is the use that is made of the EFHIA report that will make the

difference. Public health practitioners must work closely with each other and with policy

makers and other public health practitioners to identify key strategies for promoting

health equity.

Acknowledgments

We thank: the Australian Government Department of Health and Ageing who funded

the project through the Public Health Education and Research Program (PHERP); our

colleagues in ACHEIA, particularly those who tested the draft EFHIA framework in the

case study sites; and Ben Harris-Roxas in undertaking the literature review.

All outputs (including publications) developed using PHERP funding are freely

available and can therefore be accessed from any of the following websites http://chetre.

med.unsw.edu.au/hia/index.htm, http://www.deakin.edu.au/hbs/hia/ or www.niph.org.au.

S. Simpson et al. / Environmental Impact Assessment Review 25 (2005) 772–782 781

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