EDITORIALS
Health impact assessment how to start the process and make it last
Reiner Banken
Agence d'évaluation des technologies et des modes d'intervention en santé, Montreal, Canada (email: reiner.banken@aetmis.gouv.qc.ca)
Since the Lalonde Report in 1974 on "health beyond health care" in Canada, awareness of non-health sector determinants of health has been increasing (1). The World health report 2000 proposed population health as a central objective of health care systems (2) but there are few signs of the concrete mechanisms for intersectoral action that this requires. In 2000, at the Fifth Global Conference for Health Promotion, Mittelmark argued that "high-sounding, general calls to improve social responsibility for health are not sufficient to stimulate action." He proposed health impact assessment (HIA) as a device for forcing the relevant bodies to take action in favour of healthy public policies (3).
HIA has the potential to catalyse intersectoral action for health by providing information on the foreseeable consequences, both positive and negative, of proposed policies, programmes and projects. To do this, HIA would have to become part of the rules and procedures normally followed by the different decision-making bodies involved. This integration of HIA into the existing procedures has come to be known as institutionalization (4). In this sense it entails setting up patterns which condition the perception of interests, obviating some choices and facilitating others (5).
After analysing the practice of influencing government decision-making through institutionalized impact analysis, Bartlett concludes: "it makes a difference how impact assessment is institutionalized in the policy system; its policy impact is neither simple nor assured. Impact assessment does not influence policy through some magic inherent in its techniques or procedures. More than methodology or substantive focus, what determines the success of impact assessment is the appropriateness and effectiveness in particular circumstances of its implicit policy strategy."(6)
What the best strategy is for institutionalizing HIA will depend on the particular political, administrative and economic context of each country. Experience with project HIA has made clear the importance of administrative frameworks for establishing the active practices involved. Legal frameworks for environmental impact assessment (EIA) in many countries already include health impacts as a compulsory element although in practice this is often poorly done. Translating the legal framework into practice seems to require an administrative framework. For example, a memorandum of understanding signed in 1987 in Quebec, Canada, between the Ministry of Health and the Ministry of the Environment has been the key element in the subsequent development of a systematic and active HIA/EIA practice in Quebec. Mutual understanding and trust have been achieved through regular contacts between the professionals in the public health network and those in the Ministry of the Environment (7).
For the HIA of policies, the history is still too short to furnish any conclusions as to the role of administrative frameworks, though we can assume that they are important. The policy HIA process which has recently emerged in Quebec as part of a new Public Health Act may provide useful lessons for industrialized countries. The evolving experience in Thailand, described by Phoolcharoen et al. in this issue (pp. 465467), should be followed closely, as it will provide important lessons for institutionalizing HIA in similar contexts.
Although institutionalizing HIA seems desirable in order to make a concern for the improvement of health a routine part of decision-making, HIA can become inefficient in a bureaucratic environment. To maintain its long-term effectiveness, quality control mechanisms and adequate provision for external accountability are needed. Otherwise, HIA, like all impact assessment, can become a symbolic function without real effectiveness (6).
On the international level, several developments can be used as driving forces for institutionalizing HIA. The European situation, as described in this issue by Hübel & Hedin (pp. 463464), provides a strong impetus for HIA. For least-developed countries, poverty reduction strategies are among the most structured ways of developing investment policies, and HIA seems to be an ideal way to support these strategies and integrate economic and social activities with health concerns (8). In other contexts, international treaties such as the Convention on Environmental Impact Assessment in a Transboundary Context play a very important part in fostering and institutionalizing HIA (9). Integrating HIA concerns explicitly into frameworks designed for knowledge production and knowledge transfer in health systems (10) would provide an important contribution to overall capacity-building in HIA.
By making efficient use of these different developments and frameworks, the public health community will be able to foster and maintain an efficient HIA practice worldwide. 
1. Lalonde M. A new perspective on the health of Canadians a working document. Nouvelle perspective de la santé des canadiens; un document de travail. Ottawa: Government of Canada; 1974. In French. Available from: URL: http://www.hc-sc.gc.ca/hppb/phdd/pube/perintrod.htm (accessed on 18 March 2003).
2. The world health report 2000 health systems: improving performance. Geneva: World Health Organization; 2000.
3. Mittelmark MB. Promoting social responsibility for health: health impact assessment and healthy public policy at the community level. Background Technical Report for the Fifth Global Conference on Health Promotion, Mexico City, 59 June, 2000. Available from: URL:http://www.who.int/hpr/conference/products/Techreports/responsibility.pdf (accessed on 1 May 2003).
4. March JG, Olsen JP. Rediscovering institutions the organizational basis of politics. New York: Free Press; 1989.
5. Howlett M, Ramesh M. Studying public policy: policy cycles and policy subsystems. Toronto: Oxford University Press; 1995.
6. Bartlett RV. Policy through impact assessment: institutionalized analysis as a policy strategy. New York: Greenwood Press, 1989.
7. Banken R. Strategies for institutionalizing HIA. Brussels: European Centre for Health Policy; 2001. Available from: URL:http://www.who.dk/document/E75552.pdf (accessed on 1 May 2003).
8. Available from: URL:http://www.worldbank.org/poverty/strategies/review/semseries/who.pdf
9. Available from: URL:http://www.euro.who.int/healthimpact/MainActs/20011128_1
10. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Research Policy and Systems 2003;1:2.