POLICY AND PRACTICE
Health impact assessment, human rights and global public policy: a critical appraisal
Évaluation de l'impact sanitaire, droits de l'homme et politique d'intérêt mondial : étude critique
Evaluación del impacto sanitario, derechos humanos y política pública mundial: análisis crítico
Alex Scott-SamuelI; Eileen O'KeefeII
IDivision of Public Health, University of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB, England.Correspondence to Alex Scott-Samuel (email: alexss@liverpool.ac.uk).
IILondon Metropolitan University, London, England
ABSTRACT
Public policy decisions in both the social and economic spheres have enormous impact on global public health. As a result of this, and of the skewed global distribution of power and resources, health impact assessment (HIA) potentially has a key role to play in foreign policy-making and global public policy-making.
Governments, multilateral bodies and transnational corporations need to be held to account for the health impacts of their policies and practices. One route towards achieving this objective involves the inclusion of human rights assessments within HIA. International commitments to human rights instruments and standards can be used as a global auditing tool.
Methodological issues may limit the effectiveness of HIA in promoting health equity. These issues include the use of procedures that favour those holding power in the policy process or the use of procedures that fail to apply values of equity and participation. The identification and production of evidence that includes the interests of less powerful groups is a priority for HIA and would be furthered if a human rights-based method of HIA were developed.
Because HIA considers all types of policies and examines all potential determinants of health, it can play a part when foreign policy is developed and global decisions are made to treat people as rights holders. Since the human right to health is shaped by the determinants of health, developing links between the right to health assessment (that is, an assessment of the impact of policies on the right to health) and HIA - as recently proposed by the United Nations Special Rapporteur on the right to health - could strengthen the development of foreign policy and global decisions. Such links should be pursued and applied to the development of foreign policy and to the operation of multilateral bodies.
RÉSUMÉ
Les décisions d'intérêt public dans le domaine social et économique ont un impact énorme sur la santé des populations. Compte tenu de cet effet et de la distribution très inégale des pouvoirs et des ressources dans le monde, les évaluations d'impact sanitaire pourraient jouer un rôle clé dans la prise de décisions de politique étrangère et d'intérêt public concernant l'ensemble du monde.
Les gouvernements, les organismes multilatéraux et les sociétés internationales doivent être tenus de prendre en compte les impacts sanitaires de leurs politiques et de leurs pratiques. Pour atteindre cet objectif, il est notamment possible d'intégrer aux évaluations de l'impact sanitaire une évaluation du respect des droits de l'homme les normes et les instruments internationaux en faveur du respect de ces droits pouvant servir d'outils d'inspection au niveau mondial.
Des problèmes méthodologiques peuvent limiter l'efficacité des évaluations de l'impact sanitaire dans la promotion de l'équité en matière de santé. Ces problèmes peuvent résulter notamment de l'application de procédures favorisant, dans le processus politique,les détenteurs de pouvoir ou des procédures ne respectant pas les valeurs d'équité et de participation. La recherche et l'apport d'éléments prenant en compte les intérêts des groupes les moins puissants constituent une priorité pour l'évaluation de l'impact sanitaire et cette priorité sera favorisée par le développement d'une méthode pour effectuer cette évaluation fondée sur le respect des droits de l'homme.
Comme elle envisage tous les types de politiques et étudie tous les déterminants potentiels de la santé publique, l'évaluation de l'impact sanitaire pourra favoriser la prise en considération des droits des personnes dans l'élaboration des politiques étrangères et dans la prise de décisions d'intérêt mondial. Le droit humain à la santé étant conditionné par les déterminants sanitaires, le développement de liens entre le droit à une évaluation sanitaire (c'est-à-dire à une évaluation de l'impact des politiques sur le droit à la santé) et l'évaluation de l'impact sanitaire, comme l'a récemment proposé le rapporteur spécial des Nations Unies sur les droits de l'homme, pourrait étayer la mise au point des politiques étrangères et des décisions d'intérêt mondial. De tels liens doivent être recherchés et appliqués à l'élaboration des politiques étrangères et au fonctionnement des organismes multilatéraux.
RESUMEN
Las decisiones de política pública en las esferas social y económica tienen una enorme repercusión en la salud pública mundial. Debido a ello, así como a la desigual distribución mundial del poder y los recursos, la evaluación del impacto sanitario (EIS) puede tener un papel clave en la formulación de las políticas exteriores y las políticas públicas mundiales.
Los gobiernos, los órganos multilaterales y las empresas transnacionales deben rendir cuentas sobre el impacto sanitario de sus políticas y prácticas. Una vía para alcanzar ese objetivo es la inclusión de las evaluaciones de los derechos humanos como parte de la EIS. La adhesión internacional a los instrumentos y normas de derechos humanos puede utilizarse como una herramienta de control mundial.
Hay aspectos metodológicos que pueden limitar la eficacia de la EIS como medio de promoción de la equidad sanitaria. Entre ellos cabe citar el recurso a procedimientos que favorecen a quienes detentan el poder en el proceso de formulación de políticas, o a procedimientos en los que no se aplican los valores de equidad y participación. La identificación y producción de datos probatorios que incluyan los intereses de los grupos menos poderosos es una prioridad para la EIS y se vería potenciada si se desarrollara un método de EIS basado en los derechos humanos.
Teniendo en cuenta que considera todos los tipos de políticas y examina todos los determinantes potenciales de la salud, la EIS puede contribuir a que, a la hora de formular políticas exteriores y adoptar decisiones mundiales, se procure tratar a las personas como titulares de derechos. Puesto que el derecho humano a la salud se ve conformado por los factores determinantes de la salud, el desarrollo de vínculos entre el Derecho a la evaluación de la salud (es decir, a una evaluación de la repercusión de las políticas en el derecho a la salud) y la EIS -como propuso recientemente el Relator Especial de las Naciones Unidas sobre el derecho a la Salud- podría fortalecer el desarrollo de las políticas exteriores y las decisiones mundiales. Habría que crear esos vínculos y aplicarlos a la formulación de políticas exteriores y al funcionamiento de los órganos multilaterales.
Introduction
Health impact assessment (HIA) is "a combination of procedures, methods and tools by which a policy, programme 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".1 The main purpose of undertaking HIA is to move towards healthier societies through the development of "healthy public policy" - in other words, the development of policies, programmes and projects that take account of their likely or actual impacts on health. If the use of HIA is to achieve its potential, assessments need to be undertaken at regional and global levels as well as at local and national levels.
Although several alternative models exist, the HIA process includes:
· the obtainment of an agreement on the scope of the HIA in terms of depth, duration, spatial and temporal boundaries, methods and outputs;
· an analysis of policy context and content;
· a profile of areas and communities likely to be affected by the policy;
· the collection of qualitative and quantitative data on potential impacts and their distribution from stakeholders, key informants and existing evidence;
· an evaluation of the importance, scale and likelihood (and, if possible, costs) of potential impacts;
· the development of options and recommendations for action; and
· a framework for monitoring and evaluation following implementation of recommendations.
HIA is an important public policy tool because it can:2
· promote equity, sustainability and healthy public policy in an unequal and frequently unhealthy world;
· improve the quality of decision-making in health and partner organizations by incorporating the need to address health issues into planning and policy-making;
· emphasize social and environmental justice (it is usually those who are already disadvantaged who suffer most from negative health impacts);
· encourage public participation in debates about public policy issues;
· give equal status to both qualitative and quantitative assessment methods;
· make values and politics explicit, and open issues to public scrutiny;
· demonstrate that health-relevant policy is far broader than health-care issues.
HIA is used in public policy decision-making in a wide and rapidly increasing range of developed and less developed countries throughout the world. HIA has had a high profile in "developing" countries since the 1980s, where it was used mainly as part of development projects. In "developed" countries, HIA became popular during the past 15 years in Australia, Canada, New Zealand and several European countries, such as the Netherlands, Sweden and the United Kingdom. Since 2000, HIA has been used in the United States. In all of these countries the chief focus of HIA has been on the impacts affecting the physical environment, such as transport and urban development. Using HIA in this way helps spread understanding of the determinants of health among policy-makers working outside the health ministries and encourages them to take account of health impacts on residents. However, HIA remains relatively inward-looking; for example, it does not engage with the health impacts of foreign policy. This applies "in the UK, Europe and worldwide".3
The European Commission has implemented proposals to undertake integrated impact assessments of all European policies.4 Integrated impact assessments involve relatively superficial evaluations of the impact of policies along several different dimensions. The European Commission's initiative was partly in response to the range of assessments - for example, environmental, health, gender and economic - being carried out on new European policies. However, major policies require more in-depth assessments, and the European Commission has also funded the development of a European policy HIA methodology.5
At the global level, WHO has appointed an HIA adviser at its Geneva headquarters and has also played a major part in promoting the consideration of health within strategic environmental assessments. These assessments are concerned with the strategic impact of environmental policies and have been the subject of policy and legislation by the European Commission and the United Nations Economic Commission for Europe. HIA is also increasingly used by global agencies, such as the World Bank, and transnational corporations. In April 2006, the International Finance Corporation, the private sector arm of the World Bank, brought into effect a revised policy and set of performance standards on social and environmental sustainability and on disclosure of information.6 With the stated aim of improving the impact of development, the eight outcome-based standards address important determinants of health by broadening the scope of previous standards and setting new ones. The broadening of the standards ensures that they now involve all vulnerable groups in integrated environmental and social assessments, and they also assess whether forced labour or child labour has been used and whether there are standards for non-discrimination, freedom of association and collective bargaining. Wide community engagement and support are meant to be established early in a project and continue throughout the life of the project; a community grievance procedure must also be established. In addition, the revision commits borrowers to ensuring that human rights, including social rights, such as adequate housing and security of tenure, are enforced. One of the new standards is devoted to ensuring that a company has the responsibility to address the impact of its projects on a community's health and safety. The policy and standards were devised, in part, in response to criticism from civil society organizations.
Politics, values and human rights
The traditional approach to policy-making - whereby the ideal might be for HIA to become embedded in the development of all public policy globally - cannot be taken for granted. As Lock points out, HIA is both a political tool and a research tool. She includes trans-border and global policy issues as determinants of health, giving as examples international trade and the operation of multinational industries such as food, tobacco and oil.3 We live in a globalized world characterized by the dominance of neoliberal macroeconomic and trade policies. HIA has an important role in tracing causal connections between such policies and health to ensure that good public policy is made and to enable bad public policy to be actively challenged. Despite the current under use of HIA in foreign policy or state and non-state global policy, there is a large evidence base documenting such causal connections.7-9
Ingram has carried out a conceptual ground-clearing exercise to put in place a framework for the HIA of "two key... foreign policy fields that are of particular significance for health: economics and security".10 This is informed by analyses that emphasize power differentials in gender, race and migration. The exercise was prompted by the United Kingdom's inclusion of human rights-based sustainable development within the Foreign and Commonwealth Office's strategic policy priorities. Ingram acknowledges the health impact of accountability for "democratic credentials and adherence to human rights".10 In the same report, Lee demonstrates the feasibility of assessing the health impact of foreign policy by constructing a case study of the United Kingdom's taxation policy on cross-border tobacco movements.11
Among the key political determinants of health are power relations and values.12 However, commitment to widely held public health values, such as equity and participation, cannot be taken for granted in the global arena. This being the case, it will be desirable to achieve consensus on the value dimension of HIA. While all HIA methodologies include both equity and participation at some stage, in practice their application can be difficult to distinguish.
Values are more likely to be adhered to when they are included in international treaties. Human rights instruments, such as the UN Convention on the rights of the child, offer one way of identifying commitments to which policy-makers are bound. The Convention on the rights of the child includes social and economic rights - which are crucial determinants of health - and has the widest global acceptance of all human rights treaties. The reporting mechanisms used by the United Nations to assess a country's compliance with the human rights treaties to which they are signatories can be used to provide evidence relating to social and economic rights13 that can be used in HIA. In turn, HIA can promote evidence-based policy-making that affirms human rights.
Globalization promotes the emergence of cross-cultural foundational values. Since 1946, WHO has asserted that health should be treated as a human right and, since 1990, that investment in health is necessary for development.
Elsewhere, we have argued that human rights discourse in the United States has been dominated by an individualist model that fails to accommodate social and economic rights.14 Dasgupta marshals wide-ranging empirical evidence from Africa, Asia and Latin America to show that the exercise of rights improves health-status outcomes and that civic participation is instrumental to such outcomes.15 He argues further that redistributive strategies that promote the well being of populations may protect individuals. Braveman and Gruskin have shown that compliance with human rights treaties can function as a global tool for auditing people's access to health;16 we believe that HIA should have a key role in this audit process.
In 2006, the UN's Special Rapporteur on the right to health made the case for carrying out a right-to-health impact assessment and applying it to government policy. Hunt and MacNaughton provide a case study showing how policies to reduce poverty can be improved by using a synthesized method to assess their impact on human rights.17 They advocate embedding an assessment of human rights within HIA and other impact assessments; they consider this makes it more likely that governments will carry out assessments of the human rights impact of policies and that it would promote the mainstreaming of rights-based policy-making. Their method derives from Article 12 of the International covenant on economic, social and cultural rights, in which it is made clear that the right to health includes the principle that health facilities, goods and services are available, accessible, acceptable and of good quality and that this principle also applies to the underlying determinants of health.18
Methodology and policy
Methodological considerations have implications for the applicability of HIA to major policy programmes. The significance of power imbalances and the importance of maintaining a wide approach that engages with those imbalances are illustrated by the HIA of the largest World Bank-supported initiative in Africa. This initiative was an oil pipeline development that involved a loan to the Chad Oil Export Consortium, which included Exxon and the governments of Chad and Cameroon.19 Jobin, a member of the assessment team, concluded that although decision-makers addressed potentially damaging but modest factors, they did not engage with factors likely to have a major impact, such as a rapid increase in human immunodeficiency virus (HIV) incidence associated with specific, potentially modifiable, transport arrangements that assessors had identified.19 In an accompanying editorial, Kemm suggested that "health impact assessments are most likely to inform decision-making if the decision-makers 'own' the assessment and are closely involved in all the stages of the HIA ... The need that policy-makers have for impartial advice may not fit with the values of public health ... Public health practitioners value health, equity and participation, and may find it difficult to switch from arguing for these to making an impartial assessment."20 We disagree with the implications of this perspective: an HIA is not impartial if its terms of reference or its process preclude the identification of negative health impacts that fall at least partly within the policy competence of the decision-makers. Equity and the participation of stakeholder communities are fundamental values of HIA methodology: Kemm confuses the application of these values with partiality or bias. The HIA task includes identifying the leverage available to policy-makers to modify the distribution of health determinants among vulnerable sections of the population.
Decision-making at national level in low-income countries is constrained by multilateral funders, such as the World Bank, as well as by accreditation of countries for direct foreign investment. Multilateral actors shape the playing field and therefore should come within the purview of HIA. Since HIA draws on evidence, it should be as rigorous as allowed by the public health knowledge base and available resources. Producing evidence about global impacts is problematic. We are heavily reliant on knowledge about health and health care produced by powerful stakeholders, such as the World Bank, which simultaneously make policy and provide us with the information to judge the impact of their policies. This can be difficult given that the World Bank’s policy framework is derived from a contested macroeconomic paradigm.
There is an urgent need to widen the capacity for producing knowledge that can inform HIA. The use of HIA to modify potential negative impacts should include identifying health-damaging concentrations of power and locations from which alternative power structures may have a feasible chance of emerging. One of the important contributions that HIA can make at the global level is to reduce the likelihood that policies simply reflect dominant power relations. This has implications for how and by whom HIA is undertaken. The scope and methods of future HIAs should include issues that are of interest to, and promoted by, those who do not have a secure position of power within national or regional boundaries, such as poor people, migrant groups, asylum seekers and refugees.
Fortunately, in 2005, the People's Health Movement, the Global Equity Gauge Alliance and Medact established a two-yearly report on global health issues that examines the operation of organizations such as the International Monetary Fund, the World Bank and the World Trade Organization.21 This will provide helpful evidence for use in HIA. It is essential to make use of materials produced in low-income and middle-income regions, such as those in Labonte and colleagues' "framework for understanding globalization's impacts on health", which examines how powerful global actors have shaped, and are shaping, prospects for health in Africa.22 In 2005, Asher produced resources to support nongovernmental organizations in collecting evidence about health impacts by identifying violations of the right to health.23 It is apparent that service planners and providers need to develop the capacity to be able to benefit from the knowledge base and skills of community groups. Laris and colleagues have developed guidelines for staff in district health systems to enable them to create partnerships and work with civil society organizations and groups.24 They believe that effective problem solving is promoted by intersectoral collaboration and by having communities actively involved in providing information for planning and carrying out initiatives.
HIA is an emerging tool for policy-making. The establishment of the right to an HIA in international trade agreements and other key global policies represents a long-term goal. If we accept that data are limited, public health interventions have long lead-in times, public health problems are multi-causal, and most importantly, that there exist massive inequalities of power among stakeholders, it follows that an important potential outcome of the use of HIA is awareness-raising of the concept of healthy public policy within the global policy-making community and among the public.25
Discussion and conclusions
The future development of HIA in relation to foreign policy-making will depend in part on positions taken on the conceptual, methodological and value issues addressed above and on contested notions of globalization itself. HIA can be pursued using a lens of increasing width that tracks the factors that have an impact on health. It requires considerable widening to track the impact of global flows on the determinants of health and resources for health care. With the increased permeability of borders to the determinants of health, there is a pressing need to track impacts internationally to inform policy and practice across the full width of the lens. Individual countries, especially - but not only - poor ones, cannot insulate themselves against global threats to health. The more separated the economic and social resources are in the wealthy world, the less likely it is that a commitment to equity will get onto the policy agenda and the less likely it is that determinants of equity will get onto the global agenda. This is apparent from the policy debates that dominated the International Monetary Fund and World Bank throughout the 1980s and particularly in the 1990s, when the focus was on poverty-alleviating growth. This is a concept that allows humanitarian considerations to be made for disadvantaged social groups while subjecting the rest of society to widening inequalities due to the operation of market forces - which are clearly a prime candidate for HIA.
The challenge for developing healthy global public policy is to reshape "the institutional arrangements for making accountable those sites and forms of power which presently operate beyond the scope of democratic control".26 This can be promoted by extending an explicit policy framework to the international level and applying it to the determinants of equity in health status between countries. Accountability for stewardship for health, which WHO applies to national governments,27 needs to be extended to global players. This requires acknowledging and engaging with global power imbalances in the policy-making process. The widest lens would require HIA of the macroeconomic policies of major players, such as the World Bank, not just assessment of its policies for health care. Stewardship can arguably apply to impact on health, including the distribution of health status within populations.
We have given a brief outline of the possible directions that the development of HIA could take in relation to foreign policy. We recognize that these are ambitious and require development of current frameworks and practices. However, in the globalized world that we inhabit, where cross-border flows are crucial to countries, it is absurd to limit those countries' accountability to impacts on their citizens and taxpayers alone; the consequences of their policies, programmes and projects shape the health of many people outside their territory. By the same token, given the impact of the actions taken by multilateral bodies, their stated willingness to use HIA, and their endorsement of human rights discourse, it is appropriate to require that such bodies themselves be subjected to human rights-based HIA. In both the Nuffield Trust report, which identified why HIA should be applied to foreign policy and how to apply them,3,10,11 and in the UN Special Rapporteur's case study on developing a methodology for including rights assessments within HIA, the need for capacity building emerged as central: training in HIA and human rights is necessary for those who make foreign policy, and training in human rights and foreign policy is necessary for those who carry out HIA. Such capacity building is a crucial and desirable first step for this ambitious agenda.
In summary, we see the use of a human rights-based HIA both as central to the development of healthy foreign policy on a global scale and to the development of globalization as if health mattered. 
Competing interests: None declared.
References
1. European WHO. Centre for Health Policy. Health impact assessment: main concepts and suggested approach. Brussels: ECHP; 1999. (Gothenburg consensus paper.)
2. Scott-Samuel A, Ardern K, Birley M. Assessing health impacts on a population. In: Pencheon D, Guest C, Melzer D, Muir Gray JA, eds. Oxford handbook of public health practice. 2nd ed. Oxford: Oxford University Press; 2006:42-55.
3. Lock K. Health impact assessment of foreign and security policy: background paper. In: The role of health impact assessment. London: Nuffield Trust Global Programme on Health, Foreign Policy and Security; 2006:9-31.
4. Commission of the European Communities. Communication from the Commission on impact assessment. Brussels: CEC; 2002 (COM(2002) 276 final).
5. Abrahams D, den Broeder L, Doyle C, Fehr R, Haigh F, Mekel O, et al. EPHIA - European policy health impact assessment: a guide. Brussels: European Commission; 2004. Available from: http://ihia.org.uk/document/ephia.pdf
6. International Finance Corporation. Introduction to the performance standards on social and environmental sustainability, 2006. Available from: http://www.ifc.org/ifcext/enviro.nsf/Content/PerformanceStandards
7. Ravallion M, Chaudhuri S. Partially awakened giants: uneven growth in China and India. In: Winters LA, Yusuf S, eds. Dancing with giants: China, India and the global economy. Washington, DC: World Bank; 2006:157-88. Available from:http://works.bepress.com/martin-ravallion/3
8. Breman A, Shelton C. Structural adjustment programs and health. In: Kawachi I, Wamala S, eds. Globalization and health. New York: Oxford
University Press; 2006:219-233.
9. MacDonald T. Health, trade and human rights. Oxford: Radcliffe; 2006.
10. Ingram A. Health impact assessment of foreign and security policy: a critical analysis. In: The role of health impact assessment. London: Nuffield Trust Global Programme on Health, Foreign Policy and Security; 2006:32-58.
11. Lee K. Balancing health and trade policy: a health impact assessment of UK tobacco taxation. In: The role of health impact assessment. London: Nuffield Trust Global Programme on Health, Foreign Policy and Security; 2006:59-95.
12. Bambra C, Fox D, Scott-Samuel A. Towards a politics of health. Health Promot Int 2005;20:187-93.
13. O'Keefe E, Hogg C. Social inequality, policy formation and children's mental well-being. In: Hosin A, ed. Essays on issues in applied developmental psychology and child psychiatry. Lampeter, Wales: Edwin Mellen; 2000:226-38.
14. O'Keefe E, Scott-Samuel A. Human rights and wrongs: could health impact assessment help? J Law Med Ethics 2002;30:734-8.
15. Dasgupta P. An inquiry into well-being and destitution. Oxford: Oxford University Press; 1995.
16. Braveman P, Gruskin S. Health, equity and human rights; what's the connection? In: Fox D, Scott-Samuel A, eds. Human rights, equity and health. London: Nuffield Trust; 2004:9-17.
17. Hunt P, MacNaughton G. Impact assessments, poverty and human rights: a case study using the right to the highest attainable standard of health. Colchester, England: Human Rights Centre, University of Essex; 2006. Available from: http://www2.essex.ac.uk/human-rightscentre/rth/docs/ImpactAssessments9Dec06[1].doc
18. United Nations Economic and Social Council. International covenant on economic, social and cultural rights: article 12. Geneva: United Nations; 2001. (E/C.12/2001/10.)
19. Jobin W. Health and equity impacts of a large oil project in Africa. Bull World Health Organ 2003;81:420-6.
20. Kemm J. Perspectives on health impact assessment. Bull World Health Organ 2003;81:387.
21. People's Health Movement. Global Equity Gauge Alliance, Medact. Global Health Watch 2005-2006. Available from: http://www.ghwatch.org/2005-report.php
22. Labonte R, Schrecker T, Sanders D, Meeuss W. Fatal indifference: the G8, Africa and global health. Lansdowne, South Africa: University of Cape Town Press; 2004.
23. Asher J. The right to health: a resource manual for NGOs. London: Commonwealth Medical Trust, AAAS Science and Human Rights Program, Huridocs; 2005.
24. Laris P, Baum F, Schaay N, Sanders D, Kahssay H. Tapping into civil society: guidelines for linking health systems with civil society. Adelaide: Department of Public Health, Flinders University; 2006.
25. O'Keefe E, Scott-Samuel A. Health impact assessment: toward globalization as if human rights mattered. In: Kawachi I, Wamala S, eds. Globalization and health. New York: Oxford University Press; 2006:201-16.
26. Held D, McGrew A, Goldblatt D, Perraton J. Global transformations. Cambridge, England: Polity Press; 1999.
27. World Health Organization. The World Health Report 2000. Health systems: improving performance. Geneva: WHO; 2000.
(Submitted: 1 October 2006 - Final revised version received: 5 January 2007 - Accepted: 11 January 2007)