PERSPECTIVES
Developing health impact assessment in the European Union
Michael HübelI,1; Anna HedinII,2
IAdministrator, Health and Consumer Protection Directorate General, European Union
IINational Expert, Health and Consumer Protection Directorate General, European Union (email: anna.hedin@cec.eu.int)
It is not surprising that the use of impact assessments has been pioneered at local and regional levels, where the potential impacts of a proposal cover a limited geographical area and the projects tend to be specific and tangible, such as infrastructure plans for roads and airports. Evaluating the potential impact of a piece of legislation, or even a whole policy area, is much more complex; to do so at the European Union (EU) level adds further layers of complexity.
As EU interest in health matters and powers regarding them has increased, so has its interest in intersectoral approaches to health. This is attributable to several factors. First, the European Community's involvement in health is largely through work outside its narrow public health competence. Secondly, there is already a strong tradition of impact assessments within the Community, in particular environmental impact assessment (EIA). Thirdly, the Community institutions are insisting on coherent approaches to health across policies.
An initial starting point to understanding the rationale behind applying health impact assessment (HIA) within the EU is to examine the legal base of its activities. The Treaty of Rome stipulates, in Article 152, "A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities". This obligation is unique compared with most Member States in introducing a basic requirement to give consideration to possible health implications of measures and actions.
The European Commission has put into place procedures to implement the Treaty objective. These include a mandatory consultation of the Commission's Directorate General in charge of health on proposals for policy or legislation with a potential health dimension. Moreover, the Interservice Group on Health was established to coordinate health-related initiatives across different areas of Community policy. Strengthening health-related work is a central priority of the current Commission; the Community's health strategy, published in May 2000 (Communication from the Commission to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions, COM (2000) 285 final of 16.5.2000), ensures coherence and coordination between health-related policy areas.
In order to improve understanding of how different policy areas link to health, the Commission has taken an interest in the assessment of health impacts of policies, legislation and proposals, the scientific background and methodology of the impact assessment, and its application to decision-making processes. As far as the application of HIA is concerned, the Commission has drawn on national experiences across Europe set out elsewhere and on experiences with related impact assessments at Community level.
The Community's EIA legislation foresees compulsory impact assessments to be undertaken for projects of a certain size and cost. Effects on human beings, which must include health effects, are an integral part of the EIA regulatory framework. It is not surprising that in some countries HIA has developed as a sub-speciality of EIA. However, health issues tend not to be in the forefront of regular EIAs. Experience in the Community has therefore been to develop independent work on HIA, while at the same time exploring synergies with and connections to other impact assessments.
Especially at Community level, a number of key questions arise concerning the application of HIA (summarized in Box 1). These questions need to be answered convincingly before large investments in health impact assessments would be feasible. For example, the amount of research and analysis necessary to assess a particular policy or proposal will differ considerably from case to case. Decisions have to be taken on whether because of time pressures a superficial analysis is sufficient or whether in-depth analysis is required. In only a few cases, policy-makers will require full, rigorous scientific evaluations.
In addition, the assessment of potential impacts has to take into account the social, economic, cultural and climatic diversity of the Community and its Member States, especially after enlargement. It has to allow for different political traditions and citizens' customs and behaviours.
The Interservice Group on Health was instrumental in developing responses to these considerations. Following a seminar highlighting different experiences in Member States, it developed a practical guide on ensuring a high level of health protection (available from: http://europa.eu.int/comm/health/ph/key_doc/key07_en.pdf). The purpose of this guide is to serve as a toolkit for Commission services. It includes a checklist for proposal screening, background material for putting HIA in a broader perspective and references for further reading. The aim is to ensure that health impacts are dealt with and presented in a similar way across services. Based on the Gothenburg consensus paper on health impact assessment (European Centre for Health Policy, WHO-Euro, Brussels, 1999), Developing health impact assessment in Wales (The National Assembly for Wales, Cardiff, 2000) and A short guide to health impact assessment (NHS Executive London, London, 2000), the guide presents five steps for health impact assessments: screening, scoping, appraisal of potential health effects, decision-making, and implementation and monitoring. It recommends either a rapid impact appraisal, an impact analysis or an impact review. Furthermore, the guide highlights the importance of other factors, such as elements deriving from the political process, e.g. political urgency or lack of funding. Thus it provides initial guidance to assessing potential health impacts and increases awareness about the importance of taking health impacts into account when developing proposals and planning activities. In practical terms, the guide has led to a stronger involvement of health services vis-à-vis other services within the Commission which seek support in tackling health impact, in particular in response to demands from the Council and the European Parliament to have health impact analyses presented with legislative proposals (see the European Parliament's report on the impact of transport on health, A5-0014/2002, 1.22.2002).
With the intention of improving the quality and coherence of the policy development process, the Commission has recently followed national administrations in trying to streamline different impact assessments into an integrated assessment tool (Communication from the Commission on Impact Assessment COM (2002) 276 final of 5.06.2002) organized around social, environmental and economic impacts. Health impacts are specifically mentioned in the first two dimensions but actually span across the whole range of priority areas, though single sector assessments only look at certain aspects of impacts and make it difficult for policy-makers to assess trade-offs and compare different scenarios. The new impact assessment procedure, to be implemented gradually from 2003, builds on existing practices and experiences from sectoral tools and results in a common set of basic questions, minimum analytical standards and a common reporting format. The method allows for flexibility to accommodate specific circumstances of policy areas and differences between them.
The impact assessment will include two distinct stages.
The preliminary assessment. The first overview serves as a filter to decide which proposals may be subject to extended impact assessments. This will result in a short statement including an identification of the issue, desired outcomes of main policy options, and preliminary indications on expected impacts. Moreover, it should indicate whether an extended impact assessment is needed.
The extended assessment. Depending on the outcome of the preliminary assessment, the Commission decides which proposals will have an extended assessment. The main purposes of an extended assessment are to carry out an in-depth analysis of the potential impacts on society, the economy and the environment and to consult interested parties and experts.
The new Community programme on public health (Decision 1786/2002/CE (OJ L 271/1 of 9.10.2002) emphasizes developing HIA work by supporting work on criteria and methods, such as guidelines and checklists, running pilot projects and fostering joint actions with other Community policies.
Developing and disseminating practical examples of HIA is key to the establishment of the method. Pilot projects will have to demonstrate how HIA can help to improve policy-making without unduly holding up the decision-making process and creating unnecessary layers of bureaucracy. Within the choices and trade-offs made in developing, adopting and implementing policy, health needs to play an important role. Whatever method is applied to make health effects visible, the central idea is transparency. The point is to demonstrate why it was seen best to integrate health-related requirements in a particular way, and why other alternatives were put aside. Health impact assessment could play a role in this context. This will require developing a scientifically sound methodology adapted to practical needs and requirements and flexible to use in a policy-making context.
If policies and legislation are to contribute to a high level of health protection, the main objective is to put health considerations high on the agenda of policy-makers. Work on HIA will continue within the Commission, in order to improve understanding of health effects, improve methodologies and raise awareness about health in other policies. However, it must be remembered that impact assessments are but a tool. Their usefulness will be determined by whether they will help to improve the policy process and, eventually, the Community's policy output. 
Conflicts of interest: none declared.
1 This article represents the personal opinion of the authors
2 Correspondence should be sent to this author