31 August 2012

Plenary 2: Canada Experience - Institutionalisation of HIA: addressing political and administrative issues

Institutionalization of HIA in Quebec

Alain Poirier, Ministry of Health and Social Services, Quebec, Canada

  • Largest Canadian province
  • 8 million people
  • French is the official language
  • Federated structure with power sharing between federal and provincial government
  • Health and social services are integrated in the same department

Structure of health and social services system overview

  • 1980s HIA a facet of environmental assessment
  • 1990-2000s a greater push with the development of a Public Health Act (2001)
  • Two ways of covering HiAP, political one is Section 54 of the Act, Minister should be consulted on any significant public health impact

Institutionalization in HIA

Decharut Sukkumnoed, Thailand Healthy Public Policy Foundation


  • 1997 health system reform led to several significant change sin health system and beyond. A new definition of health that included social and spiritual health alongside physical and mental health.
  • Focus moved from I'll health to good health.
  • A National Act was introduced that stated that HIA was one of the main tools for healthy public policy.
  • It took over 3 years for the legislation to be passed from the point where the draft act was completed and the legislation was implemented, National Health Act 2007.
  • Section 11 of Act that people have the right to request for assessing and participating in the assessment of the impact on health of a public policy...they will have the right to express his/her opinion.
  • Explicit mention of an environmental and health impact asessment needing to be undertaken for any project which may seriously affect a community's environmental quality, natural resources or health.

HIA in the USA

Aaron Wernham, US Health Impact Project


  • America is not getting good value for its health dollar
  • Social determinants is starting to be a part of the dialogue
  • Push - More and more calls and a push with government instead in working across sectors.
  • National Prevention Council, brings teeth 14 different agencies
  • Pull - a lot of community advocacy - housing tenants, native American communities
  • First HIAs in 2000, funded by charitable foundations mainly
  • Done by community advocacy, public health, transportation agencies and private sector

Alain Poirier is back for the second part about how we go about doing institutionalisation of HIA:

  • Intergovernmental mechanism to assess health impact
  • Developed this concept of knowledge transfer
  • Monitoring and asessment of HIA practices

Executing the strategy requires:

  • Strengthening MSSS capacity - dedicated resources - funding and staff, internal government procedures
  • Creating a network of sponsors to apply the Section 54 PHA, most ministries represented
  • Producing and distributing HIA tools
  • $1.7 million budget
  • Set up and maintain a research programme
  • Ministries are using the HIA grid and are going through this exercise when reviewing new policies
  • Do review this at Secretariat General Level
We undertake

  • Strategic HIAs
  • Public health reports and science advisory reports
  • Participating in inter ministerial collaborations and other government projects
  • Ministries use their own tols and their own language
  • An evaluation found that 50% had prior involvement of MSSS and 80% took account of MSSS issues
  • Change in the way departments are working and relationships are becoming formalised
  • Need to keep going to consolidate intersectional cooperation at all levels of government



Decharut Sukkumnoed back again:

  • Combination of two main ideas: HIA as a legal requirement and HIA as a social learning proces
  • Both ideas found their way into the Act
  • Several entry points for HIA: mandatory regulatory HIA, HIA initiated by government agencies on a policy/planning process
  • Requested by local community
  • ...
Structure of organisations: in a collaborative and a contested political and social environment

  • National HIA coordination Center
  • HIA Division, DEpartment of Health
  • HIA university consortium
  • HIA private consultant club
  • Community HIA network
  • Advocacy HIA NGOs


Mandatory HIA is possibly necessary but not sufficient

  • Positive and negative experiences
  • Thai word for health means both happiness and state so it makes it easy to move beyond physical health/illness.
Learning HIA is nice but does not always work

  • Postive and negative experiences

Lessons learnt
  • Need to focus on the learning process for different stakeholders
  • Apply HIA at different levels
  • Need better understanding of policy process and creative policy interactions
  • Trying to move from push strategy to pull - instead of giving the policymakers the proposal in hopes they will take it but gaining public attention and encouraging policymakers community dialogue
  • Need to keep a collaborative and contesting environment
  • Apply HIA early in development process
  • Need to develop inactive HIA learning tools
  • Need to expand the scope of thinking for innovative solutions to healthy public policy
  • Communicating more effectively
  • More pull than push

Aaron Wernham is back for the second part:
  • US no where near a national institutionalised framework
  • There are examples at state level - Massachusetts Healthy Transportation Compact, no funding, collaborating on a first pilot, between transportation and health departments; Washington State governor can request a health impact review that addresses social determinants of health; some funding provided but now withdrawn now HIAs stopped
  • National Environmental Policy Act 1969 - health is in the Act but little health analysis is conducted, recent advocacy by Alaska Native tribes and community based groups, Alaska California Oregon and others have integrated HIA information system into EIA
  • Many other laws are asking for health analysis
  • How many existing legislative levers are out the that we are not using?

Alaska example:
  • Started as a community driven need for HIA
  • Alaska has a programme run from the Health Department and it is institutionalised
  • Role of community now less clear
NGOs are a major driver of HIA practice in the US particular in the absence of government grant funding.

Things most important in the US driving HIA use:

  • Community pull to have HIAs done
  • Public health leadership
  • Charitable foundation funding
  • Federal funding more recently as well as cross sectoral working
  • ...
Key challenges

  • Stable funding and staffing - fee for service HIAs undertaken by Departments of Health
  • Legal requirement versus incentives - legislation very unlikely and incentives is likely to be important

Does Institutionalization mean part of government or private sector that does not always serve the needs of the most vulnerable?
Is this better than before when health was not considered?

How do we avoid the risks?










Q: Is there enforcement of legislation and how does this work?

Q: Funding and resources is challenge?

Q: Need to have consistency, is this seen as health becoming stronger than they want it to?

Q: No discussion on health equity?



A: If the law is not respected within Quebec government it is a challenge given the secrecy and confidentiality of policy development, at regional level regional director of public health can ask for another sector to collaborate and look at an issue.

A: In Thailand, legislation provides the firm ground for communities to ask for a HIA, does make a difference in getting HIAs more routinely undertaken but real success is acting on the HIA. EIA is linked to EIA but analytically there are issues because the health analyses are only on physical health.

A: In the US, about law not being enforced you can argue the NEPAL already had health in it and it has not been enforced and Health agencies have not made a fuss, it is very important that a good law is a starting point but you need the organisational structure and sme work sound it to implement and action the law. EIA is seen as a legislative hurdle, bureaucracy, red tape and barrier to getting anything built.

A: The equity issue is about where is the community in the institutionalisation process, that is the key issue.


Q: Talked about tools developed for partner organisations, what is changing between the,?

A: In Quebec, we have the same tool, but we reviewed and developed material that identified what aspects of their work impacted on health. Developed a screening grid with tailored questions relevant to that MInistry


Q: In Thailand what is the criteria that determines whether a project will have a negative impact?

A: Government has developed criteria but these are used to lobby both for and against doing a HIA through the legal system. there is more use of legal and technical tactics to avoid doing HIAs.


Q: What are your experiences of working at multi level government and intersectional action on HIA?

A: In Quebec, we don't talk about HIA but talk about intersectoral action around health in various policies, there is coordination of plans at the various levels of government.

A: In US, HIA has been a way for getting intersectoral working going in practical and concrete way that can influence actual decisions particularly at local level - public health and planners, federal government are starting to this through the Prevention Council and the prevention agenda.

A: In Thailand, HIA is not the main relationship between health and non health sector, it is a tool for communities to get their voice heard in government policy and decision making.




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