Health impact assessment in CEE region: case of the former Czechoslovakia

Abstract

This paper is based on the author's personnel experience in the Slovak Republic and on information gathered during a health impact assessment (HIA) workshop with participants from Estonia, Bulgaria, Romania and Slovenia. There is a long tradition of health impact assessment in the countries of Central and Eastern Europe. In the former Czechoslovakia, legislation made in 1966, although it did not explicitly mention HIA, provided a legal basis and made the public hygiene service responsible for assessment of health impacts. However, political structures, prevalent values, reliance on limit-based comparisons, and lack of adequate training meant that HIA had little influence on decision making. Political changes since 1990 are allowing development of HIA. This experience highlights the importance of values and methods in undertaking HIA.

Introduction

Health impact assessment (HIA) is 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 (WHO, 1999). It is increasingly realised that environmental quality, workplace conditions, income and equity are more important as determinants of health than health service expenditure. Chermonas (1999) declared in his paper that the struggle for adequate funding for health care must be combined with the environmental movement's concerns for the quality of our air and water, the nutrition movement's concerns for the quality of our food, the labour movement's concern about the quality of our work, and the antipoverty movement's concerns for income and wealth equity. In her influential book, Milio (1986) argued that the health impacts of policies affecting environment, economics and patterns of living should be considered. HIA is one of several methodological and legislative tools developed to address these determinants in the last 30 years of 20th century.

The earliest developments in the Western world took place around 1970 with the establishment of environmental impact assessment (EIA) to control industrial pollution in the USA (US National Environmental Protection Act, 1970). In 1985, the European Commission introduced its first directive requiring all large development projects to be subject to environmental impact assessment. More recently EIA led to the development of other impact assessments, social, economic and most recently health Public Health Commission, 1995, Population Health Resource Branch, 1994, Fehr, 1999, Lebret and Staatsen, 1999, Berenson, 1998, Scott-Samuel, 1996, National Assembly for Wales, 1999.

In the Netherlands, an Intersectoral Policy Office within the Netherlands School of Public Health (NSPH/IPO) was established in 1996 to deal with HIA development and practice. It has produced or coordinated 20 experimental HIAs, including HIAs of the annual National Budget of the Netherlands (Put et al., 2001). In Wales, the Health Promotion Division of the National Assembly of Wales led implementation of HIA and produced the document “Developing health impact assessment in Wales” (National Assembly for Wales, 1999). In England, the Government policy document “Our healthier nation: a contract for health” declared that “major new government policies should be assessed for their impact on health” (Department of Health, 1998). In Sweden, the Federation of the Swedish County Councils together with the National Public Health Institute and the Karolinska University were the main supporters of HIA (Forbundet and Kommunforbundet, 1998). Most recently, the European Union has reasserted the importance of impact assessment of policies (European Parliament and the Council, 2002).

The enlargement of the European Union in 2004 brings 10 new countries into the Union. The new members from Central and Eastern Europe (CEE) are mostly former socialist countries with a tradition of health protection and hygiene. This paper will explore the degree to which elements of HIA are embedded in these traditions paying particular attention to the former Czechoslovakia. Although there were differences in practice between the countries of CEE, similarities in their political structures, health systems and training mean that this experience from Czechoslovakia can to a considerable extent be generalised to the whole CEE region.

Czechoslovakia split into the Czech Republic and the Slovak Republic in 1993. Since 1966, legislation (“Act on protection of health of people”) had required the assessment of health impacts. Although the term health impact assessment was not used, a regional or national hygienist was required to assess every investment project and program before it could be approved. After their separation, this requirement is still retained in the laws of both Czech and Slovak republics. In 1999 and 2000, legislation in Slovakia was significantly strengthened with the explicit inclusion of HIA in two major national policy documents, the National Health Promotion Programme and the State Health Policy. This opened a window for assessment of policy as well as programmes and projects. Unfortunately, this strong legislation did not improve health as much as might have been expected.