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Abstract
Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health. While the idea that the public’s health is affected by a broad array of social and economic policies is not new and dates back well over two centuries, what is new is the notion—increasingly adopted by major health institutions, such as the World Health Organisation (WHO) and the United Kingdom National Health Services (NHS)—that health should be an explicit consideration when evaluating all public policies. In this article, it is argued that while HIA has the potential to enhance recognition of societal determinants of health and of intersectoral responsibility for health, its pitfalls warrant critical attention. Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, compliance, plus paying for their conduct. Critical debate over the promise, process, and pitfalls of HIA needs to be informed by multiple disciplines and perspectives from diverse people and regions of the world.
- health impact assessment
- environmental impact assessment
- health policy
- human rights
- social epidemiology
- HIA, health impact assessment
- EIS, environmental impact statement
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Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health outcomes1–3 (table 1). While the idea that the public’s health is affected by a broad array of social and economic policies is not new and dates back well over two centuries,4,5 what is new is the notion—increasingly adopted by major health institutions, such as the World Health Organisation (WHO) and the United Kingdom NHS3,6,7—that health should be an explicit consideration when evaluating all public policies. At issue are the possible health consequences of myriad public and private sector activities primarily concerned with commerce, housing, transportation, labour, energy, education, etc, and their implications for meeting official targets for improving population health and reducing social disparities in health.
Definitions and characteristics of “health impact assessment” (HIA) as a “concept”, “process”, and “tool” to promote “evidence based policy making”
Starting in the mid-1990s, an emerging literature on HIA—chiefly written by and for public health professionals and advocates in the United Kingdom, Canada, and Europe—has begun to articulate why and how HIA ought be done.1–3,6–12 As an activity focusing attention on governmental obligations to health, HIA has much in common with and builds on “environmental impact assessment”1,2,13 and also has less recognised but salient links with the field of “health and human rights”14 and the concept of “human rights impact assessment.”15 By definition, HIA challenges traditional disciplinary boundaries by asking for the broadest possible evaluation of health impacts of programmes and policies lying well beyond the traditional purview of public health. Is, however, HIA an apt approach to addressing these issues?
To spur debate on this query, below we present critical perspectives on the promise, process, and pitfalls of HIA developed during one of the first multidisciplinary and multi-region international meetings focused on this topic (co-sponsored by the Harvard Center for Society and Health and the Harvard University Committee on Human Rights Studies and held at the Harvard School of Public Health, Boston, MA, Aug 16–17 2002). Explicit frameworks invoked to guide discussion were those of social epidemiology (including ecosocial theory),16,17 health and human rights,14,15 environmental and occupational health (including the precautionary principle and sustainable production),18,19 and urban planning and public health.20
THE PROMISE OF HIA
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Enhance recognition of societal determinants of health—and of intersectoral responsibility for health—among a broad audience, inside and outside the field of public health.
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Engage health professionals, policy makers, policy analysts, and affected communities in structured discussions about the public health implications of public and private sector activities, so as to inform strategic planning involving members of all of these groups.
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Encourage interdisciplinary work by health professionals, intersectoral work by policy makers and policy analysts, and creation of advocate-academic-policy initiatives to spur informed action to promote health and reduce health disparities, within and across diverse populations.
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Improve the environmental impact statement (EIS) development process21 by encouraging: (a) inclusion of health impacts on human populations as part of EIS, (b) public input from the start, rather than only at the end of the process, and (c) follow up assessment of the predictions of EIS (which rarely, if ever, is done).
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Aid the further development of human right impact assessment15 by providing guidance regarding useful criteria, structures, and processes for conducting these assessments.
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Increase awareness of the need for transparency and accountability in the policy making process and of governmental action or inaction in addressing issues identified through HIA.
Key points
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Health impact assessment (HIA) has the potential to enhance recognition of societal determinants of health and of intersectoral responsibility for health, but pitfalls of HIA warrant critical attention.
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Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, and compliance.
THE PROCESS OF HIA
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Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, and compliance:
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– Who or what initiates the conduct of an HIA? Is it mandated by law if certain conditions are met (as occurs for environmental impact assessment in the United States), or is it conducted on an ad hoc basis?
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– Who pays for the HIA? Do they have control over who conducts the HIA?
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– Who determines who will be involved in the HIA? By what process are members from affected populations, diverse academic and professional disciplines, policy makers and policy analysts, and other relevant actors chosen? Will the HIA be led by a neutral party without a direct interest in the outcome?
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– Who defines who constitutes the “affected populations”? Is there recognition of heterogeneity and inequalities within these populations, especially as related to the impacts being assessed?
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– What is the process by which agreement is reached on the approach and scope of HIA, including choice of theoretical models, methodology, and spatial and temporal scales delimiting the impact assessment? Who ensures the HIA’s conduct as an interdisciplinary and intersectoral activity that takes into account the legal and policy, and also economic, social, and cultural context in which it is conducted?
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– Who has the authority to determine if the HIA has been adequately and ethically conducted and is complete and accurate? If the parties involved in an HIA disagree on its quality or comprehensiveness, who has the authority to adjudicate disagreements?
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– Who ensures that results of an HIA are made available to the general public, rather than kept confidential?
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– If an HIA is done and the results are ignored, will there be any consequences?
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Procedurally, HIA should, from the outset, involve researchers, policy makers and analysts, and members of the affected population(s) in joint discussions regarding: (a) which kinds of questions should be asked, from what theoretical perspectives, and (b) what kinds of data are needed.
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Methodologically, HIA has the potential to improve diverse approaches (including community based participatory action research23) to developing, testing, validating, implementing, and disseminating research on policies that affect population health.
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Adequate conduct of HIA requires careful consideration of the probable time lag between when a given policy may be enacted and its expression in diverse health outcomes (that is—aetiological period). It also requires adequate baseline data and continual monitoring of the health profile of the population(s) at risk over a sufficient time period in order to assess (in quantitative or semi-quantitative terms) the actual impacts on population health, including among vulnerable subgroups.
Policy implications
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Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health outcomes.
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Mandates to conduct HIA and the costs of providing data for “evidence based policy” could potentially impede efforts to improve population health and reduce health disparities.
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Critical debate over the promise, process, and pitfalls of HIA needs to be informed by multiple disciplines and perspectives from diverse people and regions of the world.
THE PITFALLS OF HIA
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HIA can—and often has—been conducted without clear elaboration of the theoretical framework(s) guiding its implementation, and without interdisciplinary expertise, thereby producing only partial assessment of the potential health impacts and potentially protecting decision makers from unanticipated consequences.
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HIA tends to emphasise policies that enact changes rather than policies that facilitate neglect (that is—commission rather than omission), focuses on the consequences of policies rather than the determinants of policies, and also typically does not take into account policies that have been hazardous to health for extended time periods.
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While many hold that HIA is best undertaken prospectively and from a multilevel vantage, its appropriate (or optimal) timing is hard to define, and complexities of conceptualising and measuring health determinants and outcomes at multiple levels in relation to multiple pathways cannot be underestimated.
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HIA might lead to an erroneous impression that impacts can be precisely measured or predicted, hence there is a need for sensitivity analysis along with explicit consideration of plausible biological pathways connecting the policy under scrutiny to its hypothesised health impacts.
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HIA might inadvertently imply that health is the key arbiter of all policy decisions, rather than promote recognition of health as one of many outcomes meriting policy attention; charges of “health trumping all” can harm efforts to promote intersectoral and interdisciplinary work.
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HIA might become another mandated checklist activity mired in bureaucracy, rather than a catalyst to engage affected populations, academics, and policy makers and analysts in a genuine participatory process of strategic planning to improve population health and reduce health disparities.
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Costs of HIA can be very high, and it is unclear who will bear this burden or provide the necessary staff; if HIA is required as a state obligation, it could further strain resources for addressing health problems in poorer countries and poorer areas of wealthier countries.
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HIA could be a significant waste of money, time, and effort, in part because evidence of impacts is only one of many factors affecting implementation of policies.
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HIA might be an impediment to action if an emphasis on “evidence based policy” ends up precluding informed analysis of policies that cannot be studied as randomised trials23 or whose probable impact extends over a long timeframe.
In summary, HIA has the potential to be a promising tool for promoting awareness of societal determinants of health and reducing social disparities in disease, disability, death, and wellbeing. Realising this promise, however, will require considerable work and careful attention to both process and identified pitfalls. It will also require reckoning with the ultimately political nature of HIA. Whether the public’s health will concretely benefit from implementation of HIA remains unknown; achieving this objective will minimally require engaged and sustained dialogue and debate, among and between researchers, practitioners, affected populations, and policy makers and analysts, about the utility, limitations, and practice of HIA.
Acknowledgments
Thanks to the Harvard Center for Society and Health and to the Harvard University Committee on Human Rights Studies for providing funds for the conference “Health impact assessment: perspectives on the promise and pitfalls of measuring effects of policy and politics on public health,” held at the Harvard School of Public Health, Boston, MA, 16–17 August 2002. Apart from providing resources for the conference (and, in the case of the Harvard Center for Society and Health, logistical assistance), neither funder played any part in the development or submission of this paper. Participants included individual academics, members of non-governmental organisations, staff of a governmental statistical office, and technical advisors to WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS), who together represented (in alphabetical order) over 10 disciplines (economics, environmental health, history of public health, human rights, occupational health, public health surveillance, social epidemiology, sociology, statistics, and urban planning) and 10 countries (Australia, Brazil, Canada, Ecuador, France, India, Malawi, South Africa, United Kingdom, and the United States).
HIA “PROMISE AND PITFALLS” CONFERENCE GROUP (IN ALPHABETICAL ORDER)
L Badgett (University of Massachusetts, Amherst, USA), A-E Birn (New School University, NYC, NY, USA), P Braveman (University of California, San Francisco, USA), J Breilh, (Centro de Estudios y Asesoría en Salud, Quito, Ecuador), P Carter (HSPH, Boston, MA, USA), P Epstein (Harvard Medical School, Boston, MA, USA), S Koch-Weser (HSPH, Boston, MA, USA), S Kunitz (University of Rochester, NY, USA), J Lynch (University of Michigan, Ann Arbor, MI, USA), M Maluwa (UNAIDS, Geneva, Switzerland), S Marks (HSPH, Boston, MA, USA), T McMichael (Australian National University, Canberra, Australia), J Pitanguy (CEPIA, Rio de Janeiro, Brazil), T K Sundari Ravindran (WHO, Geneva, Switzerland), E Sclar (Columbia University, NYC, NY, USA), F Sihlongonyana (University of Witwaterstrand, Wits, South Africa), A Scott-Samuel (University of Liverpool, UK), M Shaw (University of Bristol, UK), D Tarantola (WHO, Geneva, Switzerland), C Victora (Federal University of Pelotas, Brazil), M C Wolfson (Statistics Canada, Ottawa, Canada)
Footnotes
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↵* Members of the HIA “promise and pitfalls” conference group are listed at the end of the article.