PERSPECTIVES
Health impact assessment and health promotion
Robert Bos
Department of Public Health and Environment, World Health Organization, 1211 Geneva 27, Switzerland (email: bosr@who.int)
Introduction
The Bangkok Charter on Health Promotion in a Globalized World, adopted at the Sixth Global Conference on Health Promotion in August 2005 (http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/), highlights the role of health impact assessment (HIA) as a key decision-making tool in development planning.
HIA is a combination of procedures, methods and tools by which a policy, programme or project may be judged with regard to its potential effects on the health of a population and the distribution of those effects within the population.1-3 The formulation of a public health management plan, consisting of safeguards, mitigation and promotional measures, is an integral part of HIA. HIA has the potential to optimize the role of health promotion in development, as it cuts across health issues, presumes specific settings and aims to address the needs of groups whose vulnerability is increased by development.
Over the past 30 years, environmental impact assessment (EIA) has evolved into a standard tool to predict adverse effects of development on the environment, as a basis for selection between different options and for mitigation of such effects as far as possible. Dealing with health in the context of EIA has been less than satisfactory. Within EIA health is invariably conceptualized narrowly rather than comprehensively, there is a bias towards environmental determinants of health at the expense of social determinants and the ensuing recommendations tend to focus on action required by the health sector, usually overlooking options to integrate health into development policies and into programme/project design and operation.
By adopting a distinct profile, HIA can overcome these constraints. HIA should run in parallel with EIA and other impact assessments, as well as the feasibility study (an economic impact assessment), so that synergies between the various studies can be exploited, while overlaps can be avoided. EIA/HIA integration at the appraisal stage is particularly critical.4
The definition of HIA includes several elements that are of direct relevance to health promotion, as referred to in the Bangkok Charter: it is a process of enabling people to increase control over their health and its determinants and, thereby, improve their health. It recognizes that the health status of communities is the result of environmental and social determinants, that it may be significantly affected by the changes in these determinants brought about by development and that it is further modulated by the actions of health services. The policy perspective is presented in Fig. 1 (web version only, available from: http://www.who.int/bulletin).
A rationale for HIA
A clear rationale for HIA emerges from the many examples which show that development without timely health considerations often leads to increased disease burdens.
An adequate HIA, as part of development planning, ensures that there will be no transfer of hidden costs to the health sector. As a result, more health sector resources are likely to be liberated for health promotional activities. Frequently, early design and operational health interventions of a preventive nature are more cost-effective than the typical curative measures that may be required once a project becomes operational. And ultimately, healthy communities themselves are essential to the success and sustainability of development.
Development aims to bring benefits to society at large. The construction of a hydropower dam, for example, may bring with it socioeconomic progress, including improved health-care facilities. The planning of such a project may also, however, overlook the adverse effects on vulnerable groups. HIA ensures a focus on the health status of vulnerable groups and provides an instrument to integrate effective risk management measures into the development process.
HIA considers both positive and negative impacts. This is perhaps where its greatest direct value for health promotion lies. A properly implemented HIA will come up with a range of recommendations for health promotional activities that otherwise might have been overlooked. This is partly because of the multidisciplinary and intersectoral nature of HIA and partly because it contains a public hearing component that helps identify opportunities based on the perceptions of members of affected communities.
HIA fits within a larger framework of best planning practice, which has been extensively discussed as part of the debate on good governance in the case of dams, for example, by the World Commission on Dams.5 All forms of impact assessment, including EIA and HIA, help to determine the best options in development planning, focusing on involuntary risk exposure and the need for risk management and compensation, including the need to invest in health promotion.
Mutual reinforcement of HIA and health promotion
In exploring the rationale for HIA, several issues become apparent in which HIA and health promotion mutually reinforce one another. Both focus on vulnerable groups and specific settings, the need for intersectoral collaboration and the economic benefits that result from acting early in the development process.
Relevance of HIA to health promotion
HIA identifies opportunities for improving health as part of development. These opportunities (such as the introduction of a safe drinking water and sanitation component into the development of irrigation schemes, or road safety measures being made part of the upgrade of a transport system) can often be included as cost-effective externalities that add considerable value to development without reducing the internal rate of return.
HIA also provides a mechanism for the engagement of other sectors in health promotion and stimulates intersectoral action. The intersectoral nature of HIA increases the chances of involving other sectors in health promotion. Behavioural change can be stimulated more credibly in joint campaigns with other sectors. For example, the promotion of healthier agricultural practices will be better accepted by local farming communities if it is supported by agricultural extension workers.
The HIA framework supports healthy public policy development. HIA criteria and procedures provide a strong framework, at the strategic level, for the formulation of healthy public policies in line with the concepts developed by the 1986 Ottawa Charter on Health Promotion.
HIA reduces the burden on the health sector, liberating resources for health promotion. Resources saved as a result of HIA-derived intersectoral public health action can be shifted from curative to preventive action. The cumulative burden of the adverse health impact of development will be significantly reduced through effective HIA. Moreover, the assessment allows the health sector to prepare better for the evolving health situation, including developing relevant health promotional actions.
Dealing with health issues early in development generally creates more opportunities for health promotion, both in terms of modifying the environmental determinants of health and anticipating social and behavioural changes that require active health promotion.
Relevance of health promotion to HIA
The settings approach used in health promotion allows local solutions to be found for local problems. The process of decentralizing health sector activities with a decreased reliance on vertical, centrally administered interventions has opened the way for a greater emphasis on health promotion by local authorities. The lessons learned from this approach can be applied in HIA, particularly in cases where the impact of individual small-scale projects is cumulatively more important than the that of one large project.
Health promotion helps create awareness of the need for HIA in development planning. Health promotion focuses on the determinants of health the basic approach of changing these determinants to improve health coincides with that of HIA. Ultimately, the achievements of health promotion, either through environmental management or through behavioural change, are relevant to the implementation of the public health management plan emerging from HIA.
Health promotion helps shape a participatory approach to health that can be applied to HIA. Community involvement is a basic component of health promotion, and the techniques developed to achieve it will also be of use in the public hearing and community consultation practices that form part of HIA.
A WHO package of essential HIA functions
Many countries now find themselves in a process of accelerated development. For sustainability's sake, their governments will need to consider the health of their population. WHO offers a comprehensive package consisting of workshops for ministry of health staff, which focuses on essential HIA functions by the health authorities and HIA management training courses, with the objective of developing skills for intersectoral negotiating skills in development planning,6 and policy seminars to create an enabling environment for HIA. These capacity-building activities already refer to health promotion, and the package is continuously reviewed and upgraded to include further elements and to ensure the involvement of health promotion staff in its implementation. HIA capacity-building is perhaps the field where strengthening the links between HIA and health promotion can have the most immediate results and benefits. 
Competing interests: none declared.
References
1. European Centre for Health Policy. Health impact assessment: main concepts and suggested approach (Gothenburg consensus paper, December 1999). Brussels: ECHP/World Health Organization Regional Office for Europe; 1999. Available from: http://www.phel.gov.uk/hiadocs/Gothenburgpaper.pdf
2. World Health Organization. Health impact assessment. Harmonization, mainstreaming and capacity building. Report of an inter-regional meeting on harmonization and mainstreaming of HIA in the World Health Organization and of a partnership meeting on the institutionalization of HIA capacity building in Africa, Arusha, 31 October-3 November 2000. Geneva: WHO; 2001. WHO document WHO/SDE/WSH/01.07.
3. Health impact assessment. Geneva: World Health Organization. See: http://www.who.int/hia/en/
4. Birley MH. Health impact assessment, integration and critical appraisal. Impact Assessment and Project Appraisal 2003;21:313-21.
5. World Commission on Dams. Dams and development, a new framework for decision-making. The report of the World Commission on Dams. London: Earthscan Publications; 2000.
6. Bos R, Birley M, Furu P, Engel C. Health opportunities in development. A course manual on developing intersectoral decision-making skills in support of health impact assessment. Geneva: World Health Organization/Charlottenlund: Danish Bilharziasis Laboratory; 2003.
(Submitted: 15 February 2006 - Final revised version received: 27 June 2006 - Accepted: 27 June 2006)