i As defined by the World Health Organization The Helsinki Statement on Health in All Policies (2013), “HiAP is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity.”
ii New Zealand has a comprehensive publicly funded public health system. In 2001, regionally based Public Health Units delivered public health services funded by the Ministry of Health. More recently, PHUs are located within 20 district health boards, which deliver and fund the full range of health services.
iii The Mãori word for meeting/workshop
iv For more information about the local tribe Ngãi Tahu see Manawa Kãi Tahu see http://ngaitahu.iwi.nz/communications/publications/manawa-kai-tahu-2016/
v In 2007 PHAC released the Whanau Ora HIA training guide. In an accompanying training workshop one of its authors stated the
As momentum grew for the ‘Healthy Public Policy’ approach, facilitated by the CCC - CDHB public health specialist, four Healthy Christchurch signatories agreed to co-fund an HIA project officer role for two years. The funding partners formed an advisory group, the Canterbury Health Impact Assessment Partnership (CHIAP), to guide this work.
This period saw many large interagency HIAs on regional and local transport plans undertaken, along with literature reviews to facilitate a shared understanding of evidence, several training workshops and the start of the development of interagency work plans. The two-year position was evaluated throughout.9 New Zealand Ministry of Health’s HIA Support Unit financially supported some of the HIA work.
In the midst of this period, Canterbury was rocked by several devastating earthquakes and thousands of smaller aftershocks (see Figure 1).
Several thousand homes in the ‘red zone’ areas were destroyed in the earthquakes (Figure 2), and much of the inner city required demolishing (Figure 3).
In response, all government agencies’ workloads and priorities were reoriented immediately.
The Ministry of Health recognised a strong champion and resource for a HiAP approach would contribute significantly to long-term community wellbeing working with a process to identify mutual gain. It provided a one-off grant to restructure the PHU to frame its work using HiAP tools founded on a social determinants of health
Figure 1. Map of seismic activity from Christchurch Earthquake Sequence
Figure 2. Map of major Residential Red Zone
area in Christchurch City Figure 3. Aerial view of city centre post earthquake
Source: GNS Science, Te Pū Ao, Lower Hutt New Zealand, April 2014
Source: Christchurch City Council
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model. A HiAP team was created at the PHU to lead this approach internally and to champion HiAP approaches with existing and new partner agencies. The Information team, the Communities team and the Environment team were also restructured around the determinants of health way of working.
Even before the built environment was severely damaged, the Canterbury community faced health and wellbeing challenges. These issues continue, with CDHB noting recently that of particular concern are type two diabetes,
dementia, obesity and hazardous alcohol intake.10 The health sector needs to address all these issues in partnership with other sectors
identifying co-benefits. Changes within the health sector were also a focus but the pressures on continued service delivery meant it was difficult to get traction within the health service delivery environment at this time.
While many challenges were identified following the major natural disaster it also provided an opportunity to move towards an explicit HiAP approach. One response was to re-form CHIAP as the Canterbury Health in All Policies Partnership (CHiAPP), a subcommittee of the Healthy Christchurch network (itself a HiAP
‘tool’), with partners CDHB, Christchurch City Council, Environment Canterbury and Ngãi Tahu.11 The HIA project officer became a senior member of the PHU’s HiAP team. One of Healthy Christchurch’s strategic goals is to support its signatories in using HiAP approaches. The CHiAPP subcommittee recognised working with HiAP approaches and tools was a significant reorientation for four large agencies and would require focus and capacity building to be successful. Throughout this time the PHU staff in the four teams took on a range of roles from practical assessments of water quality to high level strategic planning depending on the outcomes to be achieved. The staff have led pieces of work, supported partners to deliver their goals, provided background support and evidence as well as delivering capacity building initiatives.
Vision and purpose
The vision of CHiAPP is “To work together to ensure that health and wellbeing are embedded into the Partners’ policy development, planning cycle and project development.” Its objectives are for the:
1. CHiAPP Leadership Group, operating as a highly functioning and effective partnership, to develop and progress a HiAP approach in Canterbury
2. Treaty of Waitangi to inform CHiAPP’s work 3. Partners to commit to a range of HiAP
activities (e.g. capacity building both within partner organisations and externally; the use of specific resources and tools as well as undertaking impact assessments) in an annually planned approach
4. Partners to evaluate HiAP activities within their respective organisations to continually improve and assess value.12
Governance, reporting and monitoring
The CHIAPP Leadership Group met regularly to share experiences, generate projects and report on progress. Progress against the partnership’s objectives was evaluated annually and annual reports published on the PHU’s website.13 Other than the initial start-up funding, the Ministry of Health has not been involved in the governance structure locally. The Ministry of Health acknowledges the PHU takes an explicit HiAP approach in Canterbury and contract managers remain supportive and receive annual reports on these achievements. CEOs and governance bodies of CDHB and local and regional councils strongly support the HiAP approach and advocate for it at conferences and public meetings. At the 2016 scientific meeting of the NZ College of Public Health Physicians, for example, the CEOs of CDHB, Environment Canterbury, Ngãi Tahu and the Mayor of Christchurch explained how the approach was benefitting the community in the Christchurch
Applying a Health in All Policies approach to the Greater Christchurch Urban
Development Strategy: the experience to date in Canterbury, New Zealand
rebuild. Each speaker focused on a particular aspect of a HiAP approach that advanced their agency’s goals such as explicitly acknowledging local Mãori needs in the rebuild and equity of outcome.
Each agency has a nominated middle management HiAP lead who is the key contact for projects and regularly briefs senior management and governance about HiAP activity. They meet regularly to plan future work and report formally to each agency’s governance body.
Mechanisms and processes
The working relationship between agencies began with ad hoc meetings between key personnel. The regular CHiAPP meetings deepened these relationships and built trust. As the number of projects generated from these meetings grew, it showed an obvious need for a clearer process of monitoring contacts between different divisions of organisations of varying sizes while also monitoring progress on projects.
Environment Canterbury and CDHB established a joint work plan in 2012. The first simple, paper-based version identified a few joint priority areas and projects under each area and set timelines.
Progress was monitored by senior management staff and reviewed at an annual governance meeting between the two agencies. A similar process was followed with the Christchurch City Council a few years later.
As the value of this joint work plan was
realised and its complexity grew, it became an electronic portal accessible via the web from any workplace. The agreed work areas can be updated with progress and monitored at a glance and the reviewer can easily locate project plans and implementation activities.
Partners recognise the functionality of the portal.
The Greater Christchurch Partnership (GCP), which exists to deliver the goals of the GCUDS, asked to use the portal to manage its work programme with its nine partners (See Box 1 for a practical example).
The portal is the latest example of the institutional supports created for advancing a HiAP approach in Canterbury, as Figure 4 illustrates.
Establishing and maintaining partnerships
CDHB initially led and supported the HiAP work in Canterbury. The HIA on the 2007 GCUDS led to many HiAP projects and partnerships, which the government agencies and NGOs involved have actively supported.
Partnerships have been built and strengthened by regular meetings of Healthy Christchurch and CHiAPP, joint training and capacity building, shared ‘learning by doing’ projects, secondments between agencies, and joint conference presentations and journal publications. Fundamentally the partnerships are maintained by the shared work programmes and the evident benefits to all being involved in delivering higher-quality work that meets more of the agencies’ objectives. Strong support of the CHiAPP partners’ CEOs is evidenced in the ongoing financial support of the work programme.
Ultimately partnerships are based on trust – both interpersonal and between institutions.
Trust is built incrementally over time. The process of ‘learning by doing’ on projects and developing institutional supports has continued strong working relationships. To this end the HiAP team at the PHU brings a wide range of technical experiences including medical and legal practice, research and policy development, community and workforce development.
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Figure 4. Timeline of HiAP activity in Canterbury, New Zealand
Source: Canterbury District Health Board Rebranding/website created
Tripartite web portal 10 year celebration and HiAP conference
CDHB/Environment Canterbury joint work plan CDHB/CCC workplan
INSTITUTIONAL SUPPORT/ARRANGEMENTS NEW ZEALAND MINISTRY OF HEALTH SUPPORT
Health in all policies partnership
Health in all Policies team at Public Health Unit Pubic health specialist joint position CCC/CDHB
HIA Partnership Project and Officer
Healthy Christchurch partnership Publication of a
guide to HIA: a policy tool for NZ - Public Health Advisory Unit
HIA support unit -
Ministry of Health One off grant to CPH
for development HiAP approach in Christchurch
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Applying a Health in All Policies approach to the Greater Christchurch Urban
Development Strategy: the experience to date in Canterbury, New Zealand
Box 1. Updating the greater Christchurch urban development strategy
In 2015, to update the 2007 Greater Christchurch Urban Development Strategy, a small working group was formed with staff from CCC, Environment Canterbury and CDHB’s PHU. The PHU seconded a senior public health specialist full time into this role, with full support of the partners.
Having a HiAP member in the core working team demonstrated the value of working closely with partners as a ‘critical friend’ to maintain a focus on people, outcomes and wellbeing, avoiding a time-poor process that defaults to planning and systems. Over eight months the working group reviewed consultations from the previous five years, the original strategy and the post-earthquake governance and operational landscape, and prepared evidence to support an updated GCUDS.
One notable way in which 2016 GCUDS differs from its 2007 ancestor is that the health sector, through CDHB, joined the Greater Christchurch Partnership, with representation at governance, chief executive and management levels, and public health staff on all project implemention groups. The GCUDS notes CDHB’s involvement “acknowledges the legislative requirements of district health boards to promote and protect the health of people and communities, promote the inclusion and participation in society and independence of people with disabilities and reduce health outcome disparities between various population groups”.14
The Strategy’s reconsidered principles15 (see Figure 5) specifically include ‘equity’, defined as
“Treating people fairly and with respect, and recognising the different needs and aspirations of people, groups and communities. Mo tatou, a, moka uri a muri ake nei – for us and our children after us.”
Figure 5: Principles of the Greater Christchurch Urban Development Strategy
It explicitly identifies the determinants of health and wellbeing, using Barton’s health map, (Figure 6) as influencing the strategy.
The revised strategy’s strong ‘wellbeing’
focus acknowledges the importance of land use planning for healthy and resilient communities as well as ensuring certainty for developers and infrastructure providers.
This project is an example of the ways in which the Canterbury Health Sector has contributed to Sustainable Development Goal (SDG) 11 Sustainable Cities and Communities.
Ensuring Greater Christchurch is a liveable, safe,
sustainable and healthy place
through:
Leadership
Haututanga Partnership Kotahitanga
Resilience Maiatanga Equity
Tokeketanga
Regeneration
Haumanutanga Innovation
Auahatanga Integration
Kotuitanga
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Outcomes
One important outcome of the HiAP work has been to explicitly acknowledge equity as a desired outcome. The resulting changes to policy, and their relationship to the SDGs, include that:
• equity is now a guiding principle of GCUDS (SDG Goals 1 and 10)
• the rollout of the Canterbury Clean Air programme changed significantly after considering social equity issues in the HIA (SDG Goal 11)
• transport governance groups recognise and discuss equity (SDG Goals 1, 10 and 11).
GCUDS priority actions include a HiAP
approach and integrated assessments (IAs) (a methodology the HiAP team pioneered in post-disaster reconstruction). IAs, which governing authorities see as ‘business as usual’, have broadened over the last five years and have all been evaluated.14 A consistent theme is that the parties have gained value from being part of a broad, inclusive process.
It is now standard practice for governing authorities to interact regularly and early in policy development and project implementation, addressing health and wellbeing proactively from the outset. Public health advisors are routinely requested to join other agencies’ strategy development and project teams.
HiAP has strengthened regionally following the GCUDS refresh. Local authorities outside Christchurch have contributed to IAs more collaboratively, often including multiple partners.
The PHU continues to improve communication.
It profiles its work in annual reports and newsletters, and publishes all significant documents and evaluations on its website.
Capacity building within the health sector and with other stakeholders is an important focus.
Broadly Speaking, a compulsory two half-day training for all PHU staff, is offered to others in the health sector and non-health sector partners.
It introduces health determinants and the HiAP approach and gives practical tools for the workplace. Attendees are also prompting their
‘sending agencies’ around New Zealand, ranging from the defence force to other public health units, to ask for help with setting up HiAP approaches.
Figure 6. The health map
Source: Barton H. and Grant, M.
(2006). A health map for the local human habitat. The Journal for the Royal Society for the Promotion of
Health, 126 (6). 252-253. Barton and Grant 2010
The determinants of health and well-being in our neighbourhoods
Applying a Health in All Policies approach to the Greater Christchurch Urban
Development Strategy: the experience to date in Canterbury, New Zealand
Challenges and opportunities
Challenges
While health is an active partner in key decision making, challenges remain in reorienting the health sector to behave differently in its own day-to-day tasks. This is particularly difficult for a budget-constrained DHB that is managing high levels of post-disaster need.
Challenges remain in working closely and genuinely with Treaty of Waitangi partners.
Acknowledging the huge call on the resources and skills of one iwi (tribal) authority means working smarter and harder to make the work relevant.
Many partner agencies have had significant restructures, building moves and personal stressors. As a result, the PHU needs to constantly upskill and orientate new staff to the HiAP approach and clearly demonstrate its value. Staff that have been through such changes are often overworked and fatigued so thinking differently and creatively is challenging.
The strong trusting relationships discussed above have helped to walk this line of supporting while stretching colleagues.
Organisations in Canterbury are increasingly initiating conversations about their impact on health outcomes. Yet their prime responsibility and the responsibility of their elected officials are not always seen as aligning with this. HiAP has helped to create a pathway for these discussions but, with election cycles and changes in senior (and junior) staff, keeping HiAP top of mind becomes the role of many in and outside of organisations.
Above all, how to truly institutionalise the HiAP approach is a significant challenge. While partners’ documents and language increasingly recognise it, it can be easily forgotten when projects begin. The need to show the value of engaging in systematic, co-ordinated ways does not diminish. Opportunistic interactions occur that might easily have been missed. Keeping partners engaged in such structures is difficult when they have multiple demands on their time.
Opportunities
One opportunity is building on the existing strong relationships. While staff turnover is a challenge, some staff have been involved with HiAP for a long period and some move between organisations carrying HiAP knowledge and skills with them. Their involvement has prompted some of the important opportunistic interactions noted above.
Another opportunity, made possible through strengthening the Greater Christchurch Partnership, is to streamline structures so that collaboration is easier and less time-consuming for partners. Organisations and individuals that previously met with a slightly different focus can now come together with broader, more collaborative terms of reference and purpose. An opportunity already being acted on is making Healthy Christchurch into a wider regional network. Both the Urban Development Strategy and Resilient Greater Christchurch Plan identified Healthy Christchurch to lead the implementation of a ‘Health and Community’
work programme. That work programme would also lead the expanded Healthy Christchurch partnership and ensure the key aspects of CHiAPP were maintained and supported.
Many opportunities exist to leverage off existing relationships locally and across New Zealand, as reflected in the interest in and attendance at the PHU’s HiAP reflection day and conference in 2015.
The Sustainable Development Goals provide an opportunity to describe the work that the public health sector already does in the language and mandate of our partners. For example Goal 6 around water quality, Goal 4 working with Health Promoting schools programmes and Goal 1 as equity is a driver of all public health action.
As partnerships have grown and expanded, new opportunities have included:
• Early input into district and regional planning, with a central role for HiAP in guiding positive conversations about planning regionally and taking a broad, joined-up approach.
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• The view of impact assessments as ‘business as usual’ from early in plan development. New organisations in the region are also embracing these frameworks. These developments provide for multiple positive outcomes for communties and health and wellbeing.
• The recently established Resilient Cities network, supported by the Rockefeller 100 Resilient Cities Challenge. It has been an invaluable opportunity to link this work with existing regional action and to include team members experienced in HiAP.