POLICY AND PRACTICE
Bridging health and foreign policy: the role of health impact assessments
Rôle des évaluations de l'impact sanitaire dans l'établissement de liens entre politique étrangère et santé
Política exterior y evaluación del impacto sanitario
Kelley LeeI; Alan IngramII; Karen LockIII; Colin McInnesIV
ICentre on Global Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England.Correspondence to Kelley Lee (email:kelley.lee@lshtm.ac.uk).
IIUniversity College London, London, England
IIIEuropean Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, England
IVCentre for Health and International Relations, University of Wales, Aberystwyth, Wales
ABSTRACT
Health impact assessment (HIA) is an important tool for exploring the intersection between health and foreign policy, offering a useful analytical approach to increase positive health impacts and minimize negative impacts. Numerous subject areas have brought health and foreign policy together. Yet further opportunities exist for HIA to address a broader range of health impacts that otherwise may not be seen as relevant to foreign policy. HIA may also improve the quality of scientific evidence available to policy-makers. The Framework Convention on Tobacco Control offers lessons for the strategic use of HIA. However, HIA alone is limited in influencing these decision-making processes, notably when issues diverge from other core concerns such as economics and security. In such cases, HIA is an important tool to be used alongside the mobilization of key constituencies and public support.
RÉSUMÉ
L'évaluation de l'impact sanitaire est un important instrument se situant à l'intersection entre la politique de santé publique et la politique étrangère et offrant une bonne méthode analytique qui permet d'accroître les effets positifs et de réduire les effets néfastes pour la santé. De nombreux domaines intéressent à la fois la politique sanitaire et la politique étrangère. Mais il existe d'autres occasions d’examiner une gamme plus étendue d'impacts sanitaires qui pourraient de prime abord sembler ne pas concerner la politique étrangère. L'évaluation des effets sanitaires peut aussi améliorer la qualité des données scientifiques dont on dispose pour l'élaboration des politiques. La Convention-cadre de l'OMS pour la lutte antitabac permet de tirer des enseignements concernant l'emploi stratégique de cette évaluation. Mais à elle seule, l'évaluation de l'impact sanitaire ne permet d'influencer le processus de décision que de manière limitée, et ce d'autant plus qu'on s'écarte de préoccupations fondamentales ayant traità l'économie ou à la sécurité. L'évaluation de l'impact sanitaire devient alors un outil non négligeable à utiliser parallèlement à la mobilisation des groupes d'intérêts et de l'opinion.
RESUMEN
La evaluación del impacto sanitario (EIS) constituye un importante instrumento para estudiar la interrelación entre la salud y la política exterior, y brinda una útil perspectiva analítica para potenciar los efectos sanitarios positivos y reducir al mínimo los negativos. Hay muchos asuntos en los que confluyen la salud y la política exterior, pero hay otras oportunidades para aplicar la EIS a un más amplio espectro de efectos sanitarios que de lo contrario parecerían sin interés para la política exterior. La EIS también puede mejorar la calidad de los datos científicos empleados por las instancias normativas. El Convenio Marco para el Control del Tabaco ofrece algunas lecciones para usar estratégicamente la EIS. Sin embargo, ésta por sí sola tiene una influencia limitada en esos procesos decisorios, en particular cuando los problemas se apartan de otras preocupaciones básicas como son la economía y la seguridad. En esos casos, la EIS es un instrumento relevante a utilizar paralelamente a la movilización de los principales grupos interesados y el apoyo de la población.
Introduction
Health impact assessment (HIA) has been applied at the local, regional and national levels to evaluate the positive and negative health effects of a wide range of non-health policy interventions. HIAs have been used by public health departments, policy-makers, community groups, nongovernmental organizations and individuals working in a range of settings and who aim to push public health issues higher up the non health policy agenda. With few exceptions, however, HIAs have yet to be applied within the field of foreign policy in a concerted way.
HIAs have been defined by the World Health Organization (WHO) as "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 population and the distribution of effects within the population."1 These population-level effects may include the impact on health status or health outcomes,2 or may focus on a change in health risk attributed to a policy, programme, or project. Although there are various definitions of an HIA, all are concerned with the health of a population and attempts to predict the future consequences of decisions that have not yet been implemented. There are a wide range of approaches and methods used in HIAs to achieve these aims, which are beyond the scope of this paper to review. Most share the basic steps of screening, scoping, appraisal, reporting and monitoring,3 yet HIAs often adopt a flexible and adaptable approach. HIAs are intended to improve the quality of decision-making so that policies, projects and programmes in all areas lead to improved public health or minimize harm to the health of the particular population being studied. In this way, an HIA is not only a research tool, but also a means to influence policy-making.
In this article we will examine how HIAs might be usefully applied to the policy intersection between health and foreign policy. An HIA is a practical and developing tool that seeks to ensure health is on the agenda of policy-makers in all sectors and at all levels. Making use of the HIA tool ensures that policy-makers are aware of the health consequences of their decisions, accept their responsibilities with regards to health, and strengthen their links with the health sector on relevant issues.4 In addition, we consider how HIA might be better promoted to encourage the international community to give due attention to the health impacts of their actions in relation to foreign policy. There are therefore many opportunities for HIAs to draw attention to impacts not perceived as relevant to a foreign policy issue and to improve the quality of scientific evidence available to foreign policy-makers.
How useful are health impact assessments?
HIAs can influence decision-making in a number of ways. First, they can contribute to raising awareness among decision-makers of the link between health and other factors, such as the physical, social and economic environment, so that they consider health effects in planning. Second, the HIA tool can help decision-makers to identify and assess the potential impact of a specific proposal on population health and well-being, and on the distribution of those effects within the population. Third, an HIA will identify practical ways to improve and optimize the outcome of proposals, by producing a set of evidence-based recommendations that feed into the decision-making process, as well as assisting those affected by policies to participate and contribute to decision-making.1 The HIA tool is therefore located firmly within the scientific study of health, but also overlaps with governance processes. HIAs are grounded in a broad view of health and recognize that key determinants of health are influenced by a range of factors, including public policy, socioeconomic status, and the provision of and access to public services.5
Policy linkages between health and foreign policy
Foreign policy refers to the political relationship between a country and the outside world. The development of foreign policies generally concerns the protection of a country's national interests, which are traditionally defined in terms of security, economic prosperity and ideological goals. With increased globalization, interpretation of this agenda has been broadened to include issues deemed to be "low politics" and of domestic concern only, which in the past has included health.6 Conversely, policy-makers in the field of health have recognized that international trade and finance, population mobility, environmental change, and global security have clear and demonstrable implications for human health. The result has been a mutual concern for greater "intersectoral" dialogue, "policy cohesion" and "joined up" government to facilitate policy action.7,8
Health issues have, in the past, motivated foreign policy-makers to develop international law, resulting in closer dialogue between institutions. Although the HIA tool has not been systematically applied in the assessment of foreign policy to date, much can be learned from this previous experience. For example, in situations where health issues have posed a serious threat to economic interests, foreign policy-makers have been spurred to action. The earliest forms of international health cooperation were instigated by the cross-border spread of communicable diseases. The International Health Regulations, implemented initially in 1832, emerged from concerns that flourishing trade relations could be severely disrupted by certain communicable diseases.9 Since 1945, the growth of trade liberalization has led to the creation of many health-related institutional arrangements, again ostensibly to facilitate trade. These include the Agreement on Sanitary and Phytosanitary Measures, International Standards Organization classification system for food labelling, and numerous agreements on storage, transport and customs. A similar convergence of health and economic interests framed the global response to the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2002-200310 and the preparations for a potential influenza pandemic.
In addition, the link between health and national security has brought the two policy communities together on selected issues; for example, the impact of war, conflict and the arms trade on the health of populations.11 The four Geneva Conventions adopted between 1864 and 1949, along with various protocols, form an established body of international law on conduct during wartime including the treatment of casualties and prisoners.12,13 Since the early 1990s, foreign policy-makers have been concerned with the potentially destabilizing effect of severe health threats to armies, peacekeeping forces, and economic and political development, notably in countries and regions deemed strategically important.14,15
International efforts to strengthen environmental protection have led to the creation of a number of laws that have subsequently required closer cooperation between the health and foreign policy communities. The negotiation and implementation of the UN Framework Convention on Climate Change and Kyoto Protocol, for instance, has institutionalized collaboration between WHO, the United Nations Environment Programme and the World Meteorological Organization, and involved assessment of the health impacts of climate change on human health.16 Other agreements on pollution, toxic and hazardous substances, and chemicals and pesticides form a dense web of governance linking health and other sectors.
Furthermore, development assistance has been a major area of shared concern between the health and foreign policy communities. There has been increased attention to selected health issues in high-level forums such as the Group of Eight (G8), World Economic Forum, and Organization for Economic Cooperation and Development, spurred by the potential role of health in furthering foreign policy objectives. The public health community, in turn, has sought to secure increased resources for health development by drawing on such links.8 The report of the WHO Commission on Macroeconomics and Health, for example, argued that good health is critical to the economic well-being of individuals and societies.17 Other commentators have called on the international community to ensure that their obligations to human-rights, as enshrined within the Universal Declaration of Human Rights and United Nations International Covenant on Economic, Social and Cultural Rights, bring health and foreign policy-makers closer together.18
These selected examples suggest that there has been a long association between health policy and foreign policy. The linkages have been referred to as "more a marriage of convenience than of substance, with limited intramarital conversations."19 Action by governments in relation to foreign policy has been strongest when the potential impact on economic prosperity, national security, environment or development is severe. These situations have resulted in a focus on health threats that may be acute and severe, result in mass casualties, and perhaps most importantly, be geographically wide reaching. Acute epidemic infections, as well as major public health emergencies such as natural or man-made disasters, bioterrorism, and chemical and radiation accidents have received particular attention. In contrast, long-term health risks, or health risks that result in relatively minor ill-health, affect limited numbers of people or are confined geographically, have tended not to attract attention in relation to foreign policy. These health risks include most chronic diseases, mental health and small-scale accidents such as road traffic accidents.
The role of HIAs in foreign policy
We have described a somewhat restricted view of health by the foreign policy community; however, the examples cited give an insight into potential opportunities for furthering the use of HIAs. First, where health impacts are not perceived as relevant to a foreign policy issue, HIAs can draw attention to them. HIAs can generate evidence that enable the researcher to introduce new ideas, stimulate public debate and engagement, develop networks between health and foreign policy-makers, and encourage dialogue. A good example is trade and health. According to one researcher, the implementation and design of international regulations need to better account for their effects on the health system and health-related sectors: "This implies the need for a full health impact assessment of international agreements and measures that may have significant effects on health related sectors, whether directly (e.g. through constraints or influences on sectoral policies) or indirectly (e.g. through the availability of resources and input costs), before they are implemented."20
Whereas trade and health links have historically focused on the indirect effects on health-related sectors, concerted efforts by the international health community to document and draw public attention to the health impacts of specific trade measures suggest scope for modifying future policies. The Agreement on Trade-Related Intellectual Property Rights (TRIPS), for example, elicited widespread controversy over access to patented medicines by resource-poor countries. Public pressure to address this concern led to the adoption of the 2001 World Trade Organization’s Declaration on the TRIPS Agreement and the 2003 Public Health and Paragraph 6 decision, which upheld flexibilities under the TRIPS agreement to protect public health.21 Similarly, the Cartegena Protocol on Biosafety followed widespread public concern about the potential health and environmental risks from genetically modified organisms. Responding to these concerns, the protocol acknowledges the right of governments to apply the precautionary principle when regulating the trade in genetically modified food.22 Thus, amid the proliferation of multilateral, regional and bilateral trade agreements, HIAs offer foreign policy-makers an opportunity to better anticipate and more systematically address potential health impacts of specific trade measures.
A second opportunity for using HIAs is in the influencing of priorities in foreign policy. Like all policy-making, foreign policy involves making choices amid a number of competing priorities. Only selected health issues have attracted the attention of foreign policy-makers. Indeed, the protection and promotion of health may be overshadowed by other priorities that are perceived to contribute more substantially to economic prosperity or national security. For example, tobacco is the number one cause of preventable disease and mortality in Japan, whereas Japan Tobacco International (the world's third largest tobacco company) is half owned by the Ministry of Finance. Similarly, calls for the Government of the United Kingdom to end subsidies for arms exports23 have been rejected on the grounds that the industry "is a key part of ... [the United Kingdom] economy, contributing significantly to our balance of trade and employment".24 The controversy surrounding estimates of excess deaths in Iraq since 2003 illustrates how epidemiologists can even run afoul of foreign policy-makers.25,26
Although the traditional goals of foreign policy - economic prosperity and national security are - unlikely to be challenged by the health community, HIAs may be useful for influencing how these broad goals are interpreted. HIAs may be used to demonstrate how traditional goals can be furthered by positively contributing to, or minimizing, negative impacts on human health. Policy change could be achieved when shared interests can be identified. For example, the UNITAID (International Drug Purchase Facility) scheme raises finance for the prevention and treatment of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) through levies on airplane tickets as a means "to help redistribute the benefits of globalization."27 Even when different, and sometimes conflicting, moral values underpin health and foreign policy-makers, such differences do not necessarily preclude cooperation across diverse constituencies. Researchers have argued that moral clarity rather than consensus is needed: "A global health initiative can receive emphatic support from people who do not necessarily agree on the ethical foundations for their support, and in fact may very well clearly disagree with one another as to why a programme should proceed ... Advocates of global health initiatives would thus do well to proceed with a general appeal to moral concepts such as social justice and compassion, and this generality belies prudence rather than a lack of moral rigour."28
Third, HIAs can improve the quality of scientific evidence available to foreign policy-makers who must often operate within limited time-scales and with inadequate information. There is now an established and substantial body of work applying HIAs at the local and regional level.1 The basic concepts of HIAs build on and bring together many existing methods and disciplines including policy appraisal, risk assessment, stakeholder analysis, evidence-based health care, epidemiology and environmental impact assessment. The need for methods to be further developed and refined includes the "scaling up" of HIAs to the global level where the identification and measurement of causal pathways, and multiple interactions among risk factors, pose major methodological challenges.29 Applying the various stages of an HIA to foreign policy can draw on several available frameworks. For example, three models of simple, mid-level and high-level complexities have been described that link economic globalization and health.30 This framework comprises interacting levels, including super-ordinate elements. In addition, it includes a series of global, domestic, community and household contexts, and categories that include political systems, macroeconomic policies, policy capacities, geographical disparities, and health, education and social expenditures. Although not exhaustive, this framework is capable of elaboration and adaptation to particular contexts, and provides a useful template for screening the potential effects of foreign economic policy on health.
The Framework Convention on Tobacco Control: lessons for HIAs
The Framework Convention on Tobacco Control (FCTC) is notable for bringing together diverse stakeholders from around the world to achieve the world's first international health treaty. The road to its final agreement in 2004, however, was far from assured in the mid-1990s because of the presence of a politically and economically powerful tobacco industry. The industry has long been protected by its perceived status as a major contributor to tax revenues and employment. In weighing up economic interests and health impacts, most governments have chosen the former, notably in countries that are major tobacco leaf growers or cigarette exporters.
The successful negotiation of the FCTC provides several lessons for how health issues can influence foreign policy-makers, and the potential role of HIAs in this process. Of particular importance was the need to change the perceptions of foreign policy-makers that tobacco control was not relevant to their agenda. Previously, foreign policy-makers had focused their attention on selected health issues that were seen as posing severe threats to economic prosperity and national security, namely acute epidemic infections. In launching tobacco control as a cabinet-level priority within WHO, the then director-general Gro Harlem Brundtland referred to rates of mortality and morbidity from tobacco as a "global pandemic"31 and "communicated disease",32 harnessing language intended to emphasize the scale and cross-border nature of the threat. Alongside this call, and in partnership with WHO, the World Bank began a major study of the economics of tobacco.33 The resulting evidence, which directly challenged economic rationales for protecting the tobacco industry, was strategically effective as it was generated from the World Bank itself. As FCTC negotiations proceeded, evidence of large-scale tobacco smuggling as a cause of lost tax revenues and benefit to organized crime,34,35 added weight to arguments that tobacco control was relevant to economic prosperity and national security.
In addition, the FCTC succeeded in making tobacco control a higher priority. This was achieved in large part by mobilizing more accurate data on the health impacts of tobacco. Data showed that tobacco was responsible for the deaths of 4.9 million people annually, the largest cause of preventable deaths worldwide. Improved data for low- and middle-income countries was especially important for broadening support for an international treaty. Additional evidence detailing the harmful effects of second-hand smoke also reinforced the true scale of the threat to human health. There is a clear role for HIAs to contribute to the generation of such data, notably where building broad constituencies is needed to support policy change.
Finally, the FCTC process demonstrates the importance of making scientific evidence available to foreign policy-makers, as illustrated by shifts in the debate on trade and tobacco. Beginning in the mid-1980s, trade liberalization has been used to open emerging markets to transnational tobacco companies. Between 1985 and 2001, world cigarette exports more than doubled, from 354 to 922 billion cigarettes.36 There is considerable evidence that liberalization of trade in tobacco and related products leads to increased consumption.37-39 The policy debate on trade and tobacco continues to be fiercely fought, with the FCTC acknowledging these links, but containing no provisions for addressing them. Moreover, trade negotiations have been more recently shifted to the regional and bilateral levels. The Association of Southeast Asian Nations (ASEAN) Free Trade Agreement, for example, plans to cut tariffs among Member States on "sensitive" agricultural products including tobacco to 0-5% by 2010.40 The Government of the United States of America requested that China sharply reduce tariffs on tobacco imports in return for supporting its accession to the World Trade Organization.41 In this context, HIAs could provide vital analysis to enable health policy-makers to intervene more effectively in such negotiations.
Conclusions
HIAs can support efforts to maximize the positive health impacts of foreign policies, and minimize the negative. As well as putting health onto the foreign policy agenda, HIAs can generate much needed evidence to ensure particular issues and priorities are considered. There remain limits to how far HIAs alone can influence these decision-making processes, notably when issues stray too far from core concerns of economic prosperity and national security, or when powerful vested interests oppose policy change. In such cases, the strategic use of HIAs, alongside the mobilization of key constituencies and public support, will be important. 
Funding: This research was funded by the Nuffield Trust and Nuffield Health & Social Services Fund.
Competing interests: None declared.
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(Submitted: 30 September 2006 - Final revised version received: 5 January 2007 - Accepted: 9 January 2007)