Health-impact-assessment (HIA) and its role in decision making

HIA has mostly been used on projects, but it has been used on policies and programmes also. This ability to be used in a wide variety of settings is one of the strengths of the HIA approach. However the use of HIA at the strategic level, during the development of policies is one of the most exciting aspects of HIA. It can be used for policy development at local, regional, national, or international levels. Funders can also use HIAs to ensure that projects and programmes consider health, for example, the Asian Development Bank has guidelines for HIA use (Birley 1992).

Within the policy process, HIA is best used early on, while there is still maximum time to influence the policy as it develops. Many of the changes that occur within a policy occur during its development, well before it is put out for formal consultation. A close and trusting relationship with policy makers is obviously required to achieve this. The HIA influences development simply by the policy makers knowing that health will be assessed, and therefore they consider health issues more explicitly when developing the policy, and the policy maker having access to people with health knowledge on a regular basis to discuss issues with (both formally and informally).

HIA is a crosscutting approach that requires many stakeholders to be involved. This helps to develop partnerships between people and organisations – getting people together from diverse backgrounds to begin talking about health (and subsequently other topics!). Partnership working is strengthened by the HIA approach. This way of working also encourages people to see links between the policy being assessed, and other policies being implemented or developed. Often, time and resources are saved when such linkages are made, and policies are strengthened.

Decision-makers can also use the HIA to help decide between multiple policy options that are put forward to them, or to assist in deciding on policy changes based on the HIA recommendations.

The local community is a stakeholder that is included within most HIAs. Decision-makers often want to include the perceptions and opinions of the local community within policies [link to why use hia] and an HIA can help to address any community concerns. Decision-makers can then act secure in the knowledge that community views have been represented in the information they have been provided.

There are many requirements that policy makers must meet, at international, national and local levels. There is guidance/requirements to work across sectors; consider sustainability; reduce inequalities; and consider the health impact/well-being/quality of life on local communities. HIA has the ability to assist policy makers with these requirements.

There are many influences on the policy process and many different information sources feeding in, with HIA being just one of these. This is why it is so important to involve decision-makers early on in the HIA process, to alert them to the upcoming HIA recommendations and ensure there are no surprises for decision-makers.

Other than by HIA, health can be taken into account in the development of policies and programmes by:

• Joint committees, inter-sectoral councils, working groups, etc,
• Audits, providing auditors understand the link between health and other policy areas),
• Strategies and programmes that cut across policy areas (and include health),
• Within environmental impact assessment (if health is addressed),
• Budget and planning processes (if health is considered),
• Individual action of officials to influence other policies,
• Memorandum of understandings, and
• Integrated appraisal and screening tools.

Lack of relevant skills and expertise
Contact your local WHO regional office for people in your area who are undertaking HIA. Develop skills by taking part in training and reading more information on this site.

Lack of awareness and understanding
Learn more below about factors most suited to your organization/sector and use these in awareness raising activity. Send people to this website for a quick introduction.

Lack of resources
This applies to every area of work. If priority is placed on HIA, resources will follow. Using rapid (often only in days/weeks) appraisal techniques, and only doing a desk-top HIA (where community consultation does not occur) are other ways to undertake an HIA when resources are limited. Making use of information and evidence from already completed HIAs is also useful.

No recognized tools or methods
See the Health impact assessment methods and the included databases and tools for a counter argument to this.

Lack of political support
Learn more below about factors most suited to your organization/sector and use these in awareness raising activity. Use completed HIAs from the database to show how HIA has been used in other countries/organizations. Be aware of the existing interests of groups that can benefit from promoting some specific projects or business as usual situations.

Lack of time
HIA does take time, but it is worth it. HIAs can be done in a short space of time, but rapid HIAs still need a concentrated time commitment from people. A question that needs asking is, “What are the possible consequences of not doing an HIA, particularly if problems surface later, and will a lack of time be a suitable defence if the policy is challenged publicly or legally?” If an HIA is not undertaken, the proposal runs the risk of time lost later.

Other priorities get in the way
Learn more below about factors most suited to your organization/sector and use these in awareness raising activity. Use completed HIAs from the database to show how HIA has been used in other countries/organizations.

Gaps in the evidence base
There are gaps, but the use of the best available evidence is better than not using any evidence at all. HIA draws on the best available evidence and summaries are being done to draw evidence together.

WHO provides support in integrating health into environmental assessments, for example providing policy briefs and compilation of examples to learn from practice (e.g. in the waste management).

For example:

• Health impact assessment of steel plant activities in Taranto, Italy
• Learning from practice: case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region

1. During the scoping stage of HIA, explore the policy’s context by answering the questions:

• What is at stake (proposals, potential health impacts, other interests)?
• How does the policy come about (is there a consultation of stakeholders and citizens or is decision-making undertaken by one central actor) and how can HIA connect with this process?
• Who are involved in the policy making process (decision-maker(s), stakeholders, researchers and other experts, citizens)?
• What does the institutional context look like (formal decision-making procedures, communication rules, and informal relations between the several actors involved)?This exploration can identify opportunities for the HIA to link up with decision-makers and stakeholders who have similar interests. Also, the HIA has a better chance of anticipating difficulties in the process, and being able to develop strategies to address these difficulties.

2. Produce an HIA that has a plan for active dissemination of HIA messages at key stages. Announcing the HIA (when it begins, and at other key steps, etc.), disseminating preliminary findings, and using discussion groups will help to put health interests on the agenda of agencies. These steps are equally as important as producing a sound report. HIA practitioners realize that the process does not stop when the report has been produced and the decision made.

3. HIA practitioners should try to establish long-term relationships with decision-makers. Gaining the commitment of the health authority/department will help achieve this during intersectoral policy development.

4. Where appropriate, include a wide variety of stakeholders in the process, and draw on the best available qualitative and quantitative evidence. Policy makers appreciate these HIA values as they also underpin their own work. The inclusion of local communities provides policy makers with data and information that is typically hard to get, which is grounded in the realities of the local environment and is rich in experience.

5. Ensure that a longer-term follow-up of the HIA can be made to determine the actual impacts from the policy or project on the health awareness among others, on the health determinants and finally on health itself. The appropriateness of these different levels of evaluation is discussed in Evaluating your HIA.

Learn more about how to undertake a Health Impact Assessment: https://www.who.int/tools/health-impact-assessments

HIA is based on four values that link the HIA to the policy environment in which it is being undertaken:

1. democracy – allowing people to participate in the development and implementation of policies, programmes or projects that may impact on their lives;
2. equity – HIA assesses the distribution of impacts from a proposal on the whole population, with a particular reference to how the proposal will affect vulnerable people (in terms of age, gender, ethnic background and socio-economic status);
3. sustainable development – that both short and long term impacts are considered, along with the obvious, and less obvious impacts; and
4. ethical use of evidence – the best available quantitative and qualitative evidence must be identified and used in the assessment. A wide variety of evidence should be collected using the best possible methods.

• Promotes cross-sectoral working
  HIA is a participatory approach that helps people from multiple sectors to work together. working.
• A participatory approach that values the views of the community
  The HIA can be used as a framework to implicate stakeholders in a meaningful way, allowing their messages to be heard.
• The best available evidence is provided to decision-makers
  The purpose of an HIA is to provide decision-makers with a set of evidence-based recommendations about the proposal.
• Improves health and reduces inequalities
  HIA uses a wide model of health and works across sectors to provide a systematic approach for assessing how the proposal affects a population.
• It is a positive approach
  HIA looks not only for negative impacts (to prevent or reduce them), but also for impacts favourable to health.
• Appropriate for policies, strategies, plans, programmes and projects
  HIA is suitable for use at many different levels. HIA can be used on projects, programmes (groupings of projects) and policies, though it has most commonly been used on projects.
• Timeliness
  Experienced HIA practitioners can work within most time frames, undertaking comprehensive (longer) or rapid (shorter) HIAs.
• Links with sustainable development and resource management
  If the HIA is undertaken at a sufficiently early stage in the project process, it can be used as a key tool for sustainable development.

Several international policies and regulations make provisions for HIA or recommend its use, such as:

• Environmental impact assessment and strategic environmental assessment
  In almost all countries globally environmental assessment regulation exist. Internationally the Convention on EIA in a Transboundary Context of the United Nations Economic Commission for Europe (UNECE) and its Protocol on SEA build a framework for EIA and SEA which is supposed to be open for all UN Member countries. Importantly, the Protocol on SEA requires consultations to be conducted with health authorities on the likely significant effects on human health (Article 9). Furthermore, regulations of the European Union such as the SEA Directive 2001/42/EC on the assessment of the effects of certain plans and programmes on the environment and the EIA Directive 2014/52/EU on the assessment of the effects of certain public and private projects on the environment require that the environmental assessment of a proposal identifies, describes and assesses direct and indirect significant effects of a project on factors such as:

1. population and human health;
2. biodiversity […];
3. land, soil, water, air and climate;
4. material assets, cultural heritage and the landscape;
5. the interaction between the factors referred to in points (a) to (d).

• Article 152 of the Amsterdam Treaty
  The Treaty calls for the European Union (EU) to examine the possible impact of major policies on health. The treaty states that "A high level of health protection shall be ensured in connection with the formulation and implementation of all Community policies and all Community measures". The European Commission's Health Strategy proposal states that policies must ensure that public health aspects be considered in all EU decisions and actions, therefore health impact assessments should be conducted.
• Health21 – Health for all
  The 51 countries comprising the WHO European Region have a common policy framework for health development, which outlines strategies to transform national policies into practical operational programmes at the local level. After consultations with Member States and several important organizations in the Region, four main strategies for action were chosen to ensure that scientific, economic, social and political sustainability drive the implementation of  Health21. The first is that "multisectoral strategies tackle the determinants of health, taking into account physical, economic, social, cultural and gender perspectives and ensuring the use of health impact assessment".
• Environmental Health Conferences
  The 3rd ministerial conference on environmental health, held in London in 1999, recognized access to information, public participation and access to justice in environment and health as important issues. Several countries supported the idea of a protocol on strategic environment and health impact assessment, and the theme was submitted to the following environment and health conference in Budapest, in 2004. Health impact assessment was also mentioned in the following conferences in Parma (2010), Ostrava (2017) and Budapest (2023).
• Libreville Declaration
  In 2008, the Libreville Declaration on Health and Environment in Africa encouraged governments to integrate health and the environment within public policies, poverty reduction strategies and national development plans. The implementation of health and environment intersectoral programmes at all levels is considered one of the decisive factors that may lead to the achievement of the United Nations Millennium Development Goals.