The Future of Health Impact Assessment (HIA): Realizing its Potential
Health is an odd concept. What does it mean to be healthy? Are there different meanings of the word health? Is health an objective or subjective idea? These are questions that have been discussed and debated for decades. Traditionally, when people talked about health they focused on illness or injury, treatment of disease or other physical problems. While the physical aspect of health is certainly valid and does comprise a large part of what we think of as being healthy, it is not the whole story. More recently, there has been recognition of several other factors that play into whether a person is considered (or considers themselves) to be healthy. These include the non-physical aspects of health and wellness (e.g., social and economic factors) that can have a tremendous impact on health and well-being, but are often overlooked or overshadowed by physical health outcomes.
The idea of both physical and non-physical factors affecting one another and also influencing health overall is at the core of why health is so difficult to define. One of the most prevalent definitions of health was developed by the World Health Organization (WHO, 1948):
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
This definition has been widely adopted by governments and health agencies worldwide; however, in achieving its objective of being widely applicable and all encompassing, it becomes an almost impossible goal to attain. Let’s consider for a moment – when was the last time you felt complete physical, mental and social well-being? No ailments (headache, sore back, papercut), no stress or fatigue, and complete social harmony and happiness? I would argue that this is a state rarely attained by anyone. So, rather than setting an unrealistic expectation of complete health and well-being, perhaps the definition can be viewed as a laudable goal, or an ideal to strive for when tackling complex human health issues. At least, this is how I have chosen to interpret and apply the definition both in my research and in my work.
Considering how difficult it is just to define health, how do we then take the next step and assess health? This is a difficult and daunting task but it is also of the utmost importance. In order to promote economic growth and development, we must have an understanding of the impacts that are likely to arise from these undertakings. In gaining an understanding we can then seek to minimize or eliminate potential negative outcomes, while highlighting and enhancing the benefits. This is purpose of Health Impact Assessment.
What is Health Impact Assessment?
Don’t worry if you don’t REALLY know what Health Impact Assessment is – you are not alone. Every time I give a lecture at a university, or a presentation at a conference or any other venue, I ask how many people have heard of Health Impact Assessment (some hands go up), and how many people actually know what it is (most hands come down).
Health Impact Assessment (or HIA because everybody loves acronyms) is defined 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 a population, and the distribution of those effects within the population” (WHO, 1999). This definition is accurate; however, it is very broad and somewhat vague. Unfortunately, the HIA process has historically suffered from similar issues, with a large number of approaches and tools and no clear and systematic guidance on what exactly constitutes a gold-standard HIA. Fortunately, that is changing with several governments and agencies seeing the value in HIA and striving to improve and streamline to the process to make it a more consistent and highly effective tool.
The HIA process consists of several steps that HIA practitioners generally agree upon. These include: screening, scoping, assessment, recommendations, reporting, monitoring and evaluation (Figure 2).
There are several benefits of HIA including:
- The ability to consider the positive aspects of a policy or project (other assessment processes typically focus on the presence or absence of negative effects);
- The process is designed to foster positive relationships with stakeholders by considering issues important to them within the HIA process;
- The social and economic importance of health and well-being are receiving increasing attention and awareness by the governments, public health officials and communities;
- HIA provides a feasible and effective way of addressing and mitigating or enhancing effects to promote and protect human health; and,
- It can be conducted as a stand-alone process or done within an Environmental Assessment (EA) framework
HIA and EA: A Perfect Pair?
The potential for HIA as a useful decision-making tool is being realized both nationally and internationally. In 2010, Health Canada published a series of guidance documents on incorporating HIA into the EA process. Currently, the Canadian Environmental Assessment Act (CEAA) is under review with an Expert Panel charged with engaging stakeholders across the country to identify potential issues and come up with recommendations to address these issues (http://eareview-examenee.ca/). The Minister of Environment and Climate Change is specifically mandated to review the EA process to introduce new and fair processes that lead to “robust oversight and thorough environmental assessments” and also to ensure “decisions are based on science, facts and evidence and serve the public’s interest” (Government of Canada, 2016).
A report will be issued by the Expert Panel to the Minister of Environment and Climate Change and made publicly available on March 31st 2017. It is anticipated that these recommendations will include a larger focus on evaluating human health implications of designated EA projects. This shiny new version of EA in Canada is being referred to as Next-Generation (Next-Gen) EA and the Expert Panel is looking at a wide range of current issues and possible solutions.
One way that integration of health issues has been successfully demonstrated is through an adaptive HIA framework that is applied in parallel and merged into the EA process. The overall process required for HIA and EA are compatible with the same general steps being followed to identify, assess and mitigate potential effects (Figure 3).
Therefore, integrating an HIA framework within the Next-Gen EA process is very achievable. Additionally, the data and information collected, applied and generated as part of the EA process can be fed into the HIA to allow for a streamlined process that avoids duplication and improves collaboration and transparency.
Another objective of Next-Gen EA is to have “integrated, tiered assessments starting at the strategic and regional levels” (Johnston, 2016). In order to ensure that health is included in each level of EA, including Strategic, Regional, and Project-level EA, an HIA screening should be conducted in all cases. For each type of EA, the HIA would have unique and specific goals and targets; with each level of assessment informing those below (Figure 4).
Despite the level of HIA being conducted, there is a need for integrating health outcomes into the EA process in a real way. The HIA framework provides a solid foundation for consideration of physical, social, economic and cultural aspects of health and well-being within the EA process in a way that is not typically done. Additionally, including health in EA will not only promote sustainability, but also encourage corporate sustainable responsibility (CSR) around development projects within Canada.
Looking to the Future: HIA and Sustainability
Sustainability has been identified as one of the core objectives for Next-Generation EA:
“All assessments should ensure the long-term health of the environment and social values, and the equitable distribution of risks impacts and benefits” (Johnston, 2016).
This description of a sustainable EA process is directly aligned with the values and objectives of HIA. Specifically, the discussion of health including physical/environmental and social considerations, the distribution of effects and equity impacts, as well as the identification of negative and positive aspects of a proposal, are all key components of the HIA process. By adding HIA as a component of EA, it takes the EA process one step closer to the objective of reaching a more sustainable approach in Canada. Individual and community health and wellbeing are integral to ensuring that proposals are implemented in such a way that it maintains the health integrity of all Canadians. Without consideration of health, EA can never be truly sustainable.
The main goal of HIA is to assess potential positive and negative health effects resulting from proposed projects, policies and programs. Based on the results of the assessment, the HIA makes specific recommendations with the intention of enhancing positive outcomes and minimizing negative outcomes. In doing so, an HIA ensures that the proposal is more sustainable from the perspective of the health and well-being of Canadians now and in the future. Additionally, the inextricable link between health and the environment means that ecosystem health and human health should be considered together, rather than assessed in isolation.
Food for Thought: The Future of HIA
There is a need for integrating all possible health effects into the EA process. The HIA framework provides a solid foundation for consideration of physical, social, economic and cultural aspects of health and well-being within the EA process. Using existing information and data from the various EA components for inclusion in the HIA will avoid duplication of effort and promote conservation of resources. Additionally, including health in EA will not only promote sustainability of the process, but also encourage sustainable planning and development within Canada.
To ensure that all determinants of health are considered within EA, an HIA screening process could be conducted as part of all levels of EA (strategic, regional, project-level, etc.). This screening will identify potential health impacts (positive and negative) that could occur and identify whether an HIA should be conducted. Where screening indicates that an HIA is warranted, the process should use the best available evidence and adopt clear, transparent methods and tools.
Government of Canada. (2016). Review of environmental assessment processes: Expert Panel Draft Terms of Reference. Retrieved from https://www.canada.ca/en/services/environment/conservation/assessments/environmental-reviews/share-your-views/eap-draft-terms-reference/draft-terms-referenceea.html
Johnston, A. (2016). Federal Environmental Assessment Reform Summit. Executive Summary. West Coast Environmental Law.
McCallum, L. C., Ollson, C. A., & Stefanovic, I. L. (2015). Advancing the practice of health impact assessment in Canada: Obstacles and opportunities. Environmental Impact Assessment Review, 55, 98–109. http://dx.doi.org/10.1016/j.eiar.2015.07.007
McCallum, L.C. (2017). Development and Application of Strategies for Health Impact Assessment of Projects and Policies. University of Toronto. Thesis.
WHO. (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
WHO. (1999). Gothenburg Consensus Paper. Health Impact Assessment: Main Concepts and Suggested Approach. Retrieved from the World Health Organization http://www.who.int/hia/about/defin/en/