01.11.2010 Health impact assessments: a tool for sustainable policy-making
Multisectoral health policy. What’s right for the environment should also be right for human health: in the wake of the environmental impact assessment, a comparable approach for health – the health impact assessment (HIA) – is now growing in importance because it can help policy-makers assess and judge in advance the possible effects of a planned measure on public health. The HIA also increases awareness of health-policy issues in political areas unrelated to health. It can therefore help boost the transparency of the political decision-making process and sustainably improve and maintain public health.
The quality and efficiency of healthcare and the health-related behaviour of individuals are no longer sufficient to explain the health status of a population. Besides the natural environment, there are economic and social factors such as income, educational level, living conditions or social networks of friends and relatives that have a long-term effect on health and shape health status in a positive or negative way. Political decision-makers still take too little account of this multisectoral view of health when discussing the direction that economic and social policies should take. Instead, the efficiency and the cost-effectiveness of healthcare dominate the political debates. The HIA should be integrated into the political decision-making process because it enables planned political decisions to be assessed in terms of their possible benefits and harm in relation to health. In other words, an HIA can assess the potential consequences of a political decision for health in advance. Experts therefore recommend that an HIA be carried out as early as possible in the policy formulation process because the scope for drawing up improvements, variants, alternatives and flanking measures is greatest at this early stage. But no one should be under any illusion that an HIA can exactly measure or even quantify potential effects on health. In any such negotiation process, an HIA will draw up scenarios and alternatives that are as exact as possible, and therefore it serves as a supplementary assessment tool for obtaining a wide-reaching, broadly based decision-making process (see figure). Such an approach improves the quality and transparency of decisions.
Realising that not only access to high-quality preventive and curative healthcare services but also existential conditions such as peace, social status, education, employment, income, living standards, the environment and diet were key factors in health-related well-being, the WHO called for and promoted HIAs as far back as the 1970s. By emphasising these «health determinants», the WHO focused on an area to which the HIA belonged as both a strategy and a tool – the area of multisectoral health policy. According to the WHO, health policy should not be implemented in isolation, but networked with other policy areas and drawn up and maintained on a basis of shared responsibility. An HIA has a dual impact at this multisectoral level. Firstly, it will help assess the extent to which strategies and measures associated with non-health-related areas such as economic, environmental and physical development policies contribute to a framework of health-promoting conditions. Secondly, it can help other policy fields to achieve their goals.
At the European level, the UK and the Scandinavian countries in particular have developed and also partly implemented programmes for a multisectoral health policy in the last twenty years. It was at the instigation of Sweden and the UK that the EU’s Common Agricultural Policy has been investigated twice to determine its impact on health. The outcome of these two HIAs was a set of recommendations such as reducing beef subsidies, doing away with subsidies on products with a particularly high milk fat content, and raising subsidies on the production of fruit and vegetables (see article on agricultural policy in this edition of spectra).
Switzerland’s first steps in the 1990s
Any HIAs conducted in Switzerland have mostly been at the cantonal level, particularly in Geneva, Jura and Ticino. At the federal level and within the Federal Office of Public Health (FOPH), decisions taken on a multisectoral health policy in the 1990s paved the way for the HIA. These decisions include the participation of Switzerland in the Rio Earth Summit and its becoming a signatory to Agenda 21 (1992), the Federal Council’s Sustainable Development Strategy (1997), the National Environment and Health Programme (1997-2007), the positioning of the topic of gender health within the FOPH (since 1999), the Migration and Health Strategy (since 2002) and the FOPH’s Framework for a Multisectoral Health Policy (2005). The latest examples are the draft of a Federal Law on Prevention and Health Promotion (2009) and the Federal Council’s Strategy Report on Combating Poverty (2010). Concerning the draft Law on Prevention, the Federal Council can have an HIA carried out in individual cases of parliamentary and government business that have particularly far-reaching implications.
A multisectoral health policy is geared to long-term sustainability, and therefore requires far-sightedness, an open mind, an interest in other political areas, a spirit of cooperation and a change in attitude on the part of everyone involved. The fact is that many political players still think that the health authorities have sole responsibility for health policy. In addition, health-policy issues are naturally not regarded as a priority in other sectors, and in not a few cases they even conflict with other policies. The readiness to consider the long-term effects of current decisions is further diminished by the considerable time it often takes to identify the ways in which a policy intervention in another sector affects health. Consequently, the great strength of the multisectoral approach and the HIA – but also the greatest challenge – is cooperation with non-health-related policy areas to draw up win-win solutions that make a lasting contribution to public health.
Guideline for health impact assessments in Switzerland
The Swiss Health Impact Assessment Platform (HIA Platform) has, in cooperation with the Swiss Foundation for Health Promotion and with coordination by equiterre, drawn up a guideline for HIAs. It contains information on the following aspects:
– Theoretical basis of the HIA, starting from the concept of multisectoral health determinants
– Attributes of the HIA as a tool, and its integration into the decision-making process
– Synergies with other tools
– Its implications for sustainable development, which is the general strategic framework of the HIA
– Importance of the HIA at the Swiss level.
To download the guideline and obtain further information, go to the HIA platform at www.impactsante.ch
France-Vaud-Geneva physical development project Example of an HIA.
A joint agglomeration project involving Geneva and Vaud cantons and France was subjected to a prospective health impact assessment (HIA) in 2007. Traffic, local recreation areas, road safety, air quality and noise were investigated for their possible impact on health. The HIA concluded that the planned agglomeration project would be very conducive to the health and wellbeing of the population in the long term if the following HIA recommendations were taken into account in the further development of the project: expansion of the network of bicycle routes, imposition of speed limits, expansion of local recreation areas and a better distribution of jobs and homes at the heart of the agglomeration and in the regional centres. If these recommendations are implemented, health costs amounting to 163 million Swiss francs a year could be avoided by 2030.
Geneva: in the HIA vanguard
Geneva, along with Fribourg, Jura, Valais and Ticino, was one of the first cantons to promote HIA initiatives. Among other actions, Geneva has helped develop a tool for conducting HIAs. What’s more, the tool is enshrined in its Health Law, which means that the cantonal government can now subject draft laws to an HIA if they are likely to have a negative impact on health.
Wally Achtermann, Multisectoral Projects Division, Wally.Achtermann@bag.admin.ch