Health impact assessment in CEE region: case of the former Czechoslovakia
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.
Section snippets
Values, elements and legislation
The Gothenburg consensus paper (WHO, 1999) lists participation (democracy), equity, sustainable development and ethical use of evidence as basic values of HIA. In a nondemocratic society, decision making is driven by other than democratic values (authoritarian, party interest, ideology, etc.). In this context, it is difficult to see how HIA as an aid to decision making based on democratic values could be applied. Brusis (1999) describes how prior to 1990 policy was determined by administrative
Resources for HIA
HIA requires both people with appropriate skills and knowledge and infrastructure. In Czechoslovakia, the law on human health protection specified that resources for assessment were to come from the hygiene service. Hygienist are medical doctors specialised in hygiene, whose training was focused on medical knowledge and epidemiology of infectious disease and paid little attention to HIA. The staff of a hygiene station (state health institutes or public health institutes) consists mostly of
Methodology
The methodology of HIA used by the hygiene service has been influenced by descriptions of HIA elsewhere (see, for example, National Assembly for Wales, 1999).
Screening: For policy proposals, which were not considered to require an HIA, the Act 22/1966 on protection of human health requires that there should be a brief statement as to why this was concluded. This may be no more than and opinion that there would be “no influence on health”. The hygienist (or worker at hygiene station) may
Conclusions
There is considerable experience in Slovak Republic of assessing health impacts though often this falls short of HIA. There are two important lessons to be learnt from their experience before and after political change.
First, the values underlying HIA are important if HIA is to play its full part in reducing inequality and informing decision making. Second, that unless the screening and scoping stages are comprehensive and thoroughly performed, the risk assessment, decision making and
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