Health impact assessment: An aid to political decision

Scandinavian Journal of Public Health, 2008; 36: 785–788
EDITORIAL
Health impact assessment: An aid to political decision-making
JOHN KEMM
What is health impact assessment (HIA)?
Public decision-making is about choosing between
options and trading off the various consequences of
those choices so as to achieve the best possible
outcome. HIA is a process that seeks to inform
decision-making by predicting the health consequences of implementing different options. HIA
does not assume that health objectives should take
priority over the many other objectives of policy
(economic, security, environmental and so on), but
does seek to ensure that health objectives are
considered even if, in the final analysis, other
objectives are deemed to be more important. In
reality, as the article by Ravn et al. [1] in this issue
illustrates, the distinction between ‘‘health’’ and
other objectives may be arbitrary, since virtually
every domain of policy has implications for health,
and in prioritizing different objectives, the decisionmaker may merely be deciding whether direct or
indirect impacts on health are more important rather
than deciding how health will be prioritized.
It is claimed that HIA is of use at all levels of
decision-making for policies, programmes or projects.
Thus, for example, it might be applied to the national
budget or national education policy, or to a programme of agricultural development or to construction
projects such as a new highway, a dam, a supermarket
or a hospital. The HIA method chosen would probably
be different in each of these cases, but in every one the
aim would be to inform on health consequences and
allow a decision on which was better for public health.
HIA also varies in intensity. At one end of the
spectrum is the mini-HIA, which involves a few people
meeting for a few hours, relying on information that
they already have to review the health consequences of
a decision. At the other extreme may be an intensive
exercise involving several dozen people over a year or
more, doing extensive literature searches, interviewing
many informants (technical experts and residents) and
analysing in depth routinely collected statistics. In
between are HIAs involving a few people for a few
months, making less detailed investigations. In all
cases, the aim is to systematically think through the
health consequences of each option. The important
issue is to match the intensity of the HIA to the nature
of the decision under consideration.
The benefits of HIA
It is claimed that HIA allows better public decisions
and the building of healthy public policy, as called
for in the Ottawa Charter for Health Promotion [2].
Recently, during the Finnish presidency of the
European Union (EU), the need for health in all
policies was reaffirmed [3]. Additionally, HIA, by
providing a mechanism for public participation, may
make the decision-making process more transparent,
giving greater ownership and acceptance of the
final decision. HIA has also proved to be a very
effective tool for fostering cooperation between
different agencies, such as different ministries of
national government or the health section and the
Correspondence: John Kemm, West Midlands Public Health Observatory, Birmingham Research Park, Birmingham B15 2SQ, UK. E-mail:
[email protected]
# 2008 the Nordic Societies of Public Health
DOI: 10.1177/1403494808098042
786
J. Kemm
administrative section of local government.
Furthermore, even if an HIA is not found to be
helpful for the particular decision under consideration, it leaves the decision-makers more aware of
health issues and therefore more likely to consider
them when making their next decision. Additionally,
it can make the population more aware of how their
health is affected by local conditions, and empower
them to protect their own health.
The steps of HIA
of the decision-makers, but the HIA should serve to
guide and assist them with these stages.
When doing an HIA, it is important to consider
public participation in order to ensure that HIA is
more than a simply technocratic exercise. There are
numerous guides to HIA. Readers may find ‘‘The
Merseyside guide to HIA’’ or ‘‘More than a
statement of the crushingly obvious – A critical
guide to HIA’’, or a guide written in Sweden
‘‘Health Questions’’, of use (these guides can be
found in the HIA gateway under Guides and
Evidence on www.hiagateway.org.uk).
As usually described, HIA consists of six steps:
1.
2.
3.
4.
5.
6.
screening;
scoping;
appraisal;
recommendations and reporting;
decision-making;
implementation and monitoring.
Screening is the stage at which it is decided whether
a decision raises sufficient health issues to merit an
HIA. In practice, there are few decisions that do not
raise health issues, and the decision on whether to
undertake an HIA rests more on the degree of
controversy, the political context and the availability
of resources than the likelihood of health impacts.
The second stage, scoping, includes deciding the
paths by which health is likely to be impacted, the
areas on which to focus enquiry, the areas that will
be excluded, the lines of evidence that will be used,
who and what resources will be involved, the
timetable for the assessment, and how the enquiry
will be pursued. The tool described by Ravn et al.
[1] takes us someway towards identifying the main
modes of impact, and might be considered as rather
more than a screening tool.
The appraisal stage is the main stage of the HIA
and involves following the lines of enquiry identified
in the scoping stage, gathering evidence and
attempting to predict the nature, the direction
(increase or decrease) and the magnitude of impacts.
In the recommendation and reporting stage, suggestions based on the analysis produced in the appraisal
stage are made as to how adverse impacts can be
avoided or minimized and how positive impacts can be
maximized. Recommendations may also be made as to
possible health consequences that ought to be monitored. After this, a report of the HIA is prepared and
communicated to those who have to make the decision
before they have to make their choice of options.
The final three stages of the HIA, decision-making,
implementation and monitoring, are the responsibility
Making predictions in HIA
The claim that HIA predicts the future consequences
of implementing different options is a bold one and
should be carefully scrutinized. The basis for prediction is a causal path diagram identifying each link
leading from implementation of the option to an
impact on health. For example, a path could be:
N
N
construction of new road R exhaust emissions R
asthma episodes
construction of factory R employment opportunities R better mental health
The first step in assessing health impacts would then
be to estimate the level of exhaust emissions that
would be produced and how this would affect air
quality or how many jobs would be created. It should
be noted that the necessary skills to make these
estimates are possessed by specialists in disciplines
other than public health, and therefore cooperation
with these disciplines is essential. The second step
would be to assess how many people would be affected
by the change in air quality and how severely, or how
many people would have their mental health affected
by the newly created jobs. In some cases, it is possible
to use the exposure and dose–response curve method
familiar to epidemiologists in order to determine the
magnitude of impacts, but in others (such as the
employment example) the size of health impacts is
more difficult to predict.
Quantification of impacts
Decision-makers need to know not only that there
will be impacts but how big those impacts will be.
For example, it is little help to learn that a proposal
may cause some extra deaths without knowing
whether that means one extra death in a population
of 1,000,000 in 100 years (negligible), or one
extra death in a population of 10,000 in a year
Editorial
(unacceptable). Impacts resulting from emissions [4]
and injuries resulting from road traffic have been
well quantified in some HIAs. Modelling may be
further developed to allow better prediction of the
size of impacts resulting from changes in other
determinants. The approach used in models such as
PREVENT deserves to be more widely applied in
HIA. However, quantification of impacts remains an
area where little progress has been made, and very
few HIAs have given useful estimates of magnitude
of impact [5]. With participatory methods, quantification is especially difficult.
Decision support, not decision-making
Early descriptions of HIA failed to distinguish the
roles of decision-maker and assessor. It is the job of
the health impact assessor to assist the decisionmaker, not to make the decision for them. In some
situations, the decision-maker will want to be led
towards the decision with a recommendation from
the assessor as to which option is most favourable for
health. In others, the decision-maker will wish to
reserve the choice to him or herself, and will want
the assessor to stop at identifying the likely consequences of each option. The health impact
assessor will need to clarify at an early stage how
they are to assist the decision-making.
Obviously, a degree of uncertainty is attached to
any prediction, and it is important for the HIA
report to communicate not only the assessment of
what impacts are likely, but also the uncertainty
attached to that prediction. Decision-makers need to
understand that HIA gives them best judgement, not
infallibility [6].
Originally, HIA was conceived as a quality
assurance step towards the end of the decisionmaking process. However, HIA is probably more
useful if it is able to influence the decision in its
development stages, when change is easier. One
should therefore be seeking to make HIA a process
that runs in parallel with the decision-making
process rather than one that starts when the decision
is almost made.
So has HIA influenced decision-making?
The effectiveness of HIA is the title and subject of a
recently published book [7]. In many cases, the HIA
has merely been used as a justification for a decision
that has effectively already been made, but there are
examples where HIA appears to have influenced the
decision. The HIA of Finningley airport in the UK is
believed to have been the reason why a residents’
787
group was established to monitor the operation of
the airport, and the HIA of Berlin airport was
probably the reason for considerable changes to the
proposal. It is claimed that the HIA of the Kings
Cross reconstruction project in London was the
reason why overnight working on the site was not
permitted. An HIA of a Welsh government scheme
to subsidize home energy improvements was probably the cause of several refinements to the policy
before it was published. One has to be cautious in
ascribing causes for a decision change, even when
the decision-maker states that they were influenced
by the HIA. Nonetheless, evidence is building that in
some situations HIA can result and has resulted in
healthier decisions.
Application of HIA in Scandinavia
A survey of the use of HIA at three political levels,
state, region and municipality, in Denmark in 2003
did not reveal much interest in HIA as part of the
routine policy consideration [8]. The structural
reform of Denmark from 2007, which reduced the
number of municipalities from about 275 to 98 and
decentralized the main responsibility for health
promotion and disease prevention to municipalities,
has increased interest in HIA. About 25% of Danish
municipalities would now like to include HIA in
their policy-making process [9]. Thus, the Danish
case reflects a bottom-up process based on a
delegation of responsibility for health to municipalities rather than an initiative coming from a ministry
or legislative body.
In Sweden, there has been a longer tradition of
using HIA, and one of the first HIAs of policy (EU
Common Agricultural Policy) was produced in 1996
by the Swedish National Institute of Public Health
[10]. A set of tools was developed for using HIA in
decision-making in Sweden [11], and their use in the
Stockholm Health Care District has been described
[12]. A survey conducted in 2001 showed that several
Swedish municipalities and county councils were
using HIA and that others were thinking of doing so
[13]. Consideration of some health aspects is required
in environmental impact assessment (EIA), but sometimes a further HIA is done to complement the EIA, as
was the case for route 73 [14].
The author of this editorial is unaware of surveys
on HIA use from other Scandinavian countries.
Conclusion
There is growing interest among policy-makers in
HIA, and a general approach of systematically
788
J. Kemm
reviewing the health consequences of different
choices must be helpful. A great deal of progress
has been made in developing ways for health impact
assessors to support decision-makers and ways for
them to make more reliable predictions, but there is
still a great deal of scope for improvement.
References
[1] Ravn AK, Nicolaisen H, Linnrose K, Folkersen MW,
Kraemer RJ, Gulis G. Screening tool development for health
impact assessment of large administrative structural changes.
Scand J Public Health 2008;36:789–94.
[2] World Health Organization Ottawa Charter for Health
Promotion, Available at: http://www.who.int/healthpromotion/
conferences/previous/ottawa/en/.
[3] Stahl T, Wismar M, Ollila E, Lahtinen E, Leppo K. Health
in all policies: prospects and potentials. Helsinki: Ministry of
Social Affairs and Health; 2006.
[4] Mindell J, Barrowcliffe R. Linking environmental effects to
health impacts: a computer modelling approach for air
pollution. J Epidemiol Community Health 2005;59:1092–8.
[5] Veerman JL, Barendregt JJ, Mackenbach JP. Quantitative
health impact assessment: current practice and future
directions. J Epidemiol Community Health 2005;59:
361–70.
[6] Thomson H. HIA forecast: Cloudy with sunny spells later?
Eur J Public Health 2008;18:436–38.
[7] Wismar M, Blau J, Ernst K, Figueras J. The effectiveness
of health impact assessment: scope and limitations of
supporting decision-making in Europe. Brussels: European
Observatory on Health Systems and Policies; 2007.
[8] Aarestrup AK, Due TD, Kamper-Jorgensen F. De kommunale sunhedspolitikker i Danmark – en kortlaegning [Health
policy in Danish municipalities 2007 – a survey]. Copehagen:
National Institute of Public Health; 2007 (in Danish).
[9] Bistrup ML, Kamper-Jorgensen F. Sundhedskonsekvensvurderinger. Koncept. Perspektiver. Anvendelse i stat,
amter og kommuner [Health impact assessment. Concept.
Perspectives. Application with government, counties and
municipalities]. Copenhagen: National Institute for Public
Health; 2005 (in Danish).
[10] Dahlgren G, Nordgren P, Whitehead M. Health impact
assessment of the EU Common Agriculture Policy.
Stockholm: Swedish National Institute of Public Health;
1996.
[11] Federation of Swedish County Councils, Swedish
Association of Local Authorities. Focusing on health: how
can the health impact of policy decisions be assessed?
Stockholm: Federation of Swedish County Councils; 1998.
[12] Finer D, Tillgren P, Berensson K, Guldbrandsson K,
Haglund BJA. Implementation of a health impact assessment (HIA) tool in a regional health organisation in Sweden:
a feasibility study. Health Promotion Int 2005;20:277–84.
[13] Berensson K. HIA at the local level in Sweden. In: Kemm J,
Parry J, Palmer S, editors. Health impact assessment:
concepts, theory, techniques and applications. Oxford:
Oxford University Press; 2004. p 213–20.
[14] Knutsson I, Linell A. HIA speeding up the decision making
process; the reconstruction of route 73 in Sweden. Case Study
8. In: Stahl T, Wismar M, Ollila E, Lahtinen E, Leppo K,
editors. Health in all policies: prospects and potentials. Helsinki:
Ministry of Social Affairs and Health; 2006. p 161–76.
John Kemm
Director of West Midlands Public Health
Observatory
Birmingham, UK