Yesterday I joined more than forty people at a workshop that explored a question that has haunted my professional life for the better part of two decades: how do we move health impact assessment (HIA) from episodic enthusiasm to genuine, ongoing practice?

The Wellbeing for Future Generations: Lessons from Wales and Building HIA Capacity in Australia workshop was jointly organised by the Cities Institute and the International Centre for Future Health Systems at the University of New South Wales, and was convened by A/Prof Fiona Haigh and Dr Jinhee Kim. It focused on the lessons from Wales' remarkable journey toward legislating HIA, combined with reflections from Australian practitioners about how they’ve navigated the changing use of HIA in Australia. What emerged, for me, wasn't just a comparison of two countries, but a deeper conversation about time, fear, and the architecture of institutional change.

This matters because decisions about transport infrastructure, housing developments, planning, and social programs all shape (costly) health outcomes, but health considerations remain marginal in these processes.

The tide turns

There's a palpable sense that interest in HIA is having a resurgance in Australia. After pioneering work in the early 2000s, Australia’s HIA use gave way to what Fiona today described as "fragmented and champion-driven" activity.

However we're seeing renewed momentum. EPA Victoria is doing focused work on HIA, the enHealth guidelines are being updated, conversations about integration with planning are occurring in different jurisdictions, there seems to be increased receptiveness from local government to consider wellbeing and health across a range of activities.

The tide seems to be coming back in.

But tides are cyclical. The crucial question isn't whether we're experiencing renewed interest; it's whether we can institutionalise approaches that persist after champions move on, when political priorities shift, or when the next public health crisis demands attention.

This is where Wales has done so well but also gives us plenty of insights, not as a template to copy, but as a case study in patient institution-building.

Eight years: playing the long game

Professor Liz Green's keynote traced Wales' path from the Well-being of Future Generations Act to the statutory HIA requirements coming into force in April 2027, which is described in more detail on the Wales Health Impact Assessment Support Unit website.

One detail from Liz’s talk stood out: it took eight years from focused advocacy to the legislation being enacted.

This temporal dimension matters profoundly, but sits uncomfortably with the rhythms that drive most of our work. Media cycles operate in days. Political attention spans in weeks or months. Electoral cycles in three to four years. Research funding rounds in annual competitions. But meaningful institutional change, the kind that shifts how organisations and systems routinely operate, moves on different timescales.

Wales has embedded long-term thinking as one of its five ways of working within the Well-being of Future Generations Act (2015). This detail matters. The recognition that sustainable development, health equity, and genuine stakeholder participation require longer-term horizons is baked into how the Welsh Assembly sees its role, and sees itself as distinct. The question for Australia is can we sustain advocacy and capacity-building efforts across timeframes that outlast individual politicians, program managers, or funding cycles?

Fear, trust, and the culture challenge

Perhaps the most important observation from the presentations and panel discussion was about fear. Fear of scrutiny. Fear of loss of control. Fear that HIA will slow decision-making, expose uncomfortable truths, or empower communities to challenge projects that authorities have already decided. The panel, made up of Liz, Fiona, Jinhee, Kelly Andrews from Healthy Cities Australia, and Dr Emma Quinn from the NSW Ministry of Health, had a wide-ranging discussion. One idea that was suggested was that legislation can counter this emotional, fear-driven response by creating statutory obligations that override individual reluctance.

I’m unsure about this. Does legislation alone ever really change culture, or do people find ways to subvert intent while technically complying? The Welsh model includes transparency requirements, publication obligations, and potential for judicial review—mechanisms designed to make perfunctory compliance more difficult. Yet even with these safeguards, there's recognition that building genuine commitment requires action beyond legal mandates.

This is where recent work applying implementation science frameworks to HIA may be relevant. An international team led by Dr Tara Kenny and Dr Monica O’Mullane from University College Cork (disclosure: including me!) used the Consolidated Framework for Implementation Research (CFIR) to map barriers and facilitators to HIA’s adoption across five domains:

• the innovation itself (HIA as a method),
• outer setting (political and policy context),
• inner setting (organisational capacity),
• individuals (knowledge and attitudes), and
• process (how implementation unfolds).

What implementation science might add

The Kenny et al. review synthesises evidence from 45 studies, revealing patterns that could inform a revamped Australian approach to HIA’s use. Three findings stand out for me.

The first thing is that the early stages of HIA, screening and scoping, are critical not just for technical and procedural reasons, but because this is when critical decisions get made about whose voices matter, what impacts get attention, and how equity will be focused on. The paper suggests that "HIA implementation that encapsulates HIA’s core values of equity and participation require attention at the earlier stages of the HIA and may be difficult to retrofit post scoping." This has pretty far-reaching implications: if we're still serious about participatory, equity-focused HIA, we need to resource and scaffold these early phases differently.

The second issue is that capacity challenges operate across multiple levels and domains simultaneously. It's not just about training individuals to conduct HIAs, or even about developing organisational resources and in-house infrastructure. It's about supportive policy environments, intersectoral partnerships, access to data, alignment with existing impact and policy assessment processes, and broader public health advocacy that creates awareness of the broader determinants of health. The review identifies strategies spanning all five CFIR domains, from clarifying HIA's relative advantage over other assessment tools, to building networks and partnerships, to ensuring adequate funding and dedicated staff.

Third and most fundamentally, the review concludes that “building wider HIA support, awareness, and capacity essential to progressing HIA is dependent on wider public health advocacy and addressing challenges specific to HIA as a method and tool.” In essence, HIA institutionalisation isn't a narrow technical project. It’s embedded within broader efforts to advance Health in All Policies approaches, strengthening understanding of the determinants of health and wellbeing, and shifting how we make decisions about policies, programs, and projects that shape population health.

No wonder it’s been difficult. It involves far more complexity than most simple “innovations”. Yet the alternative, where we continue to make decisions that deliberately or inadvertently exacerbate health inequities, carries its own costs These costs remain largely invisible because we don't systematically assess them and don’t hold people to account for them.

Toward adaptive institutionalisation?

At the end of the workshop, and thinking about Tara’s paper on HIA and implementation science, I came up with an idea I want to explore further: a model of adaptive institutionalisation for HIA in Australia.

Rather than pursuing a single pathway, whether that's a mandate, capacity building, or voluntary adoption (and HIA has always taken heterogeneous forms), what I’m calling an adaptive institutionalisation approach would recognise that different strategies suit different contexts and phases of readiness. This approach acknowledges that political windows of opportunity are unpredictable but can be prepared for. It focuses on capacity building strategies that work with, rather than against, political cycles and extant institutional cultures.

Thinking about CFIR's process domain, this might involve:

Assessing context before acting

Rather than simply following the stepwise HIA procedures uncritically and unconsciously, there may be value in systematically appraising where support and momentum already exists within different contexts, what potential champions already exist and how they could be linked to the HIA process, how HIA timing could align with decision making processes (and how the HIA could be tweaked if it doesn’t align), and what broader policy opportunities could be leveraged. Many experienced HIA practitioners do these things routinely (often due to past failures and errors) but they need to be signposted, made explicit, and acknowledged in HIA guidance.

Staged implementation that matches readiness

Different jurisdictions, sectors, and decision-making contexts sit at different points along the HIA implementation journey. Some might be ready for integration with existing assessment processes. Others need much more foundational awareness-raising of enabling concepts. Others still might benefit from demonstrations of HIA internally that build trust and show practical value. We’ve had to do all of these at different times in New South Wales, but the approach has often been tacitly (and tactically) adaptive rather than guided by a framework.

Attending to timeframes

We need to focus on multi-year strategies that might survive electoral and funding cycles, while also identifying a few short-term wins that build momentum and demonstrate value. Timing and timeliness has been a recurrent theme in HIA effectiveness research. Wales' eight-year journey (within its even longer twenty year journey) suggests we need patient institution-building alongside responsive opportunism. We’ve been doing this within the HIA field, but sometimes not owning up to it explicitly or publicly.

Building trust

Tara’s review emphasises transparency throughout the HIA process, rigorous methodology, and clear documentation of decision-making as essential for building trust in HIA as a process and practice. This matters because it's the foundation for addressing the fear and resistance issues mentioned above that legislation alone can’t overcome.

Conceiving of HIA capacity as part of broader health equity infrastructure

Re-connecting HIA existing health equity initiatives, Health in All Policies approaches, Healthy Cities networks, and cross-sectoral partnerships. This is being done anyway, but it can leverage existing action and make sure that health promotion remains at the heart of HIA along with health protection.

What this means in practice

For those of us working on HIA in Australia, I’ve been reflecting on yesterday’s workshop and I think there are several implications:

1. We need to get serious about the early stages of HIA (screening and scoping), recognising these as moments where equity and participation get embedded or excluded.
2. We need to map the Australian landscape more systematically. Where is momentum building? What existing assessment and planning processes might HIA enhance or complement? Where do champions exist, and what support do they need? Which policy windows are opening, and how can we prepare to move when they do? (I feel like this is constantly changing, so knowledge that’s derived ad hoc gets out of date quickly)
3. We need to develop and revamp resources and guidance that support context-sensitive adaptation rather than prescriptive standardisation of HIA processes.
4. We should document and share both successes and challenges more systematically. The evidence base for HIA effectiveness in Australia is relatively good, but we still need honest and public reporting about what didn't work and why, not just spin or examples we’d like to showcase.
5. We need to (re)connect HIA advocacy and capacity-building with broader public health movements in Australia for health equity, sustainable development, and participatory governance. HIA isn't an end in itself, it's a way to get to better decisions that protect and promote population health and equity.

The question we left with

As I was facilitating the panel discussion towards the end of the workshop, I posed a thought experiment: imagine we reconvened in three years to find HIA genuinely reinvigorated in Australia, with more widespread use, demonstrable impacts on health equity, energy and momentum. What would have happened to get us there?

The answers pointed toward both top-down enablers (policy frameworks, funding, legislation) and bottom-up drivers (community demand, practitioner networks, demonstrated value for different sectors). The discussion also mentioned the need for both quick wins (showing value and responsiveness) and more slow, patient institution building (developing sustainable infrastructure).

I'd add one more element to what was discussed, drawn from our conversation about time and Wales' experience. We need to have realistic expectations about the temporal rhythms of institutional change. Eight years from advocacy to legislation. Twelve years before that to build capacity, develop guidance, train practitioners, and shift organisational cultures.

This doesn't mean twenty years of waiting. It means strategic, sustained effort across multiple fronts and building on the work that’s already been done over decades in Australia to further develop capacity, seize opportunities, create demand, (continuing to) demonstrate value, form and expand partnerships, shift narratives, and yes, when circumstances align, pursuing legislation and regulatory frameworks.

The tide may be coming in, but tides don't build seawalls (to torture a metaphor). We still need intention, resources, coordination, and time.

The question is whether we're prepared for the long work of adaptive institutionalisation. If we can be patient enough for the timeframes involved, strategic enough to work across multiple levels and domains, and committed enough to sustain effort when the returns won’t be immediately evident.

Wales shows it's possible. Implementation science may give us ways of formalising and describing the hard work of institutionalising HIA that’s already been undertaken. In Australia there are still meaningful challenges and opportunities. What happens next depends on whether we can translate enthusiasm into the kind of sustained (generational?), multilevel effort that genuine institutionalisation will require.

Thanks

Many thanks to all participants at the 1 December workshop participants, particularly Liz Green for sharing Wales' experience, and to the panelists Kelly Andrews (Healthy Cities Australia), Dr Emma Quinn (NSW Ministry of Health), A/Prof Fiona Haigh (UNSW International Centre for Future Health Systems), and Dr Jinhee Kim (UNSW Cities Institute) for their insights. The workshop was jointly organised by the Cities Institute and the International Centre for Future Health Systems.

References

CFIR Research Team. (2025). The Consolidated Framework for Implementation Research. Center for Clinical Management Research. https://cfirguide.org

Kenny, T., Harris-Roxas, B., McHugh, S., Douglas, M., Green, L., Haigh, F., Purdy, J., Kavanagh, P., & O’Mullane, M. (2025). Routemap for health impact assessment implementation: Scoping review using the consolidated framework for implementation research. Health Promotion International, 40(3), daaf080. https://doi.org/10.1093/heapro/daaf080

This post first appeared on the Harris-Roxas Health blog.