Challenges to integrate health impact assessment into environmental assessment procedures: the pending debate

ABSTRACT

Sooner or later, Health Impact Assessment (HIA) will be conducted as a legal requirement (instead of a voluntary process) in a variable number of public and/or private projects worldwide. The Spanish Public Health Act 2011 introduced HIA into the national legal system but its regulatory development remains incomplete. This delay is partially justified because of the current lack of resources and the associated costs, which are not exclusively a Spanish problem, according to literature. Therefore, this situation invites stakeholders to promote the integration of HIA into other administrative consolidated procedures, such as strategic environmental assessment (SEA) of policies, plans and programmes and environmental impact assessment (EIA) of projects. However, SEA and EIA procedures unveil well-known weaknesses that have been publicly reported for decades. It is, therefore, befitting to promote a previous interdisciplinary debate on both the desirability of integrating HIA into both SEA and EIA, and the way of doing so. This article intends to serve as a starting point for discussion by practitioners involved in defining the role of HIA into environmental assessments and vice versa.

KEYWORDS:

• EIA
• follow-up programs
• hia
• public health
• public participation
• sea

1. Introduction

The right to health does not only imply the access to health services but also a wider range of factors that can help us lead a healthy life. Indeed, it has long been accepted that health and its determinants are strongly influenced by policies and projects outside the health care sector (Mindell et al. 2003; Almeida et al. 2017). The World Health Organization (WHO) has emphasized on intersectoral action for health for a long time and health impact assessment (HIA) is a tool which expands the consideration of Public Health at decision-making level through policies, plans and programs in all sectors (Krieger et al. 2003; Ollila 2011). During the past two decades, HIA has been slowly institutionalized in a growing number of countries all over the World (Green et al. 2019), but the majority of HIAs are done voluntarily, outside regulatory requirements (Haigh et al. 2013; Green et al. 2019). For instance, HIA is not a legal requirement in the European Union (EU) and its status may contrast with disciplines such as strategic environmental assessment (SEA) of policies, plans and programmes and environmental impact assessment (EIA) of projects (Fischer et al. 2018). In this sense, it is worth noting that health protection is defined in both SEA Directive 42/2001/EC and EIA Directive (2014/52/EU) in the EU (Diallo et al. 2018; Fischer et al. 2018). However, there is a sense among many public health professionals that both SEA and EIA did not adequately address project impacts on community and individual health (Morgan 2012). In addition, a comprehensive HIA requires cooperation between sectors (Claudio et al. 2018) and the authority responsible for environmental assessment is not directly concerned about Public Health which, in fact, is perceived as an obstacle to effectively achieve HIA objectives (Lock and McKee 2005).

The Spanish Public Health Act 2011 (BOE 2011) introduced HIA into the national legal system but its regulatory development still remains incomplete at a national level. Only a single regional regulation has been released by the Autonomous Community of Andalusia (Figure 1), in Southern Spain (Vela-Ríos et al. 2016). Usually, this delay is justified, among other reasons, because of the current lack of resources and the associated costs, for both administrations and project developers. In this context, policy makers and stakeholders are tempted, at both national and international levels, to promote the integration of HIA into other consolidated procedures, such as SEA and EIA (Ahmad 2004; Sanz et al. 2012). Even when there is a political will to integrate different substantive aspects, it may be difficult to do it (Fischer and Cave 2018), because making the principles and values of HIA effective require a previous debate on the compatibility of aims and procedures.

Figure 1. Institutionalization of HIA in Spain.

2. Integration of health impact assessment into multidisciplinary impact assessment systems

HIA is considered a promising strategy for implementing health in all policies (HiAP) across a range of sectors (Schuchter et al. 2014; Ashton et al. 2018). On the other hand, EIA together with SEA are tools used by most countries around the World to assist environmental decision-making in order to contribute and promote sustainable development from planning to project level (Hulett and Diab 2002; Kwiatkowski and Ooi 2003; Morgan 2012). SEA and EIA encompass many parts that are helpful to meet some HIA's goals and there is a large controversy about the convenience of conducting separate forms of impact assessment (Bruhn-Tysk and Eklund 2002; Simpson et al. 2005). In addition, most environmental assessment programs around the world encourage the consideration of human health impacts (Steinemann 2000). For instance, the United States National Environmental Policy Act soon established broad requirements to consider health and human welfare (Birley 2011) as did the European Directive 2014/52/EU (OJEU 2014) which includes health in the EIA process. Also, the Canadian Environmental Assessment Act (CEAA 2012) allows for Health Canada to review the predicted environmental impacts of a project that may affect human health (McCallum et al. 2018). However, historically, information on health has often been omitted, or has been incomplete and dispersed during those other impact assessment processes, because of an environmental-centric approach and a lack of guidance on health for the actors involved in specific interventions subject to EIA or SEA (Steinemann 2000; Fischer et al. 2010; Vohra et al. 2016; Chang et al. 2017; Diallo et al. 2018; McCallum et al. 2018; Roué Le Gall et al. 2018; Linzalone et al. 2019).

In Spain, the Spanish Act on Environmental Assessment 2013 (BOE 2013) included the requirement to assess potential impacts on human health in both EIA and SEA procedures. Nevertheless, a recent research (on a sample of more than 100 environmental impact studies) reveals that only 55% acknowledged this issue and, in most cases, very superficially and insufficiently (Espigares and Gómez Sal 2018). Previously, the aspects related to human health were never fully considered with due attention in interventions subject to EIA or SEA (Casas et al. 2011).

3. Public participation: is it real or fake?

In general, policy makers often place great emphasis on public participation, which is considered a fundamental component in all forms of impact assessment (Hartley and Wood 2005; Glucker et al. 2013). In the EU, the fact that public participation increases the transparency of the decision-making process and it guarantees the right of access to environmental information is emphasized (OJEU 2003; Bond et al. 2004). In this sense, the perception of communities about the extent to which participative processes can influence project design and decision-making is considered critical for the effective spreading of HIA (Bacigalupe et al. 2009). Furthermore, HIA emphasizes, in theory, the need to identify specific disadvantaged groups and the public is encouraged to obtain an informed opinion throughout different phases of the procedure (Sandín-Vázquez and Sarría-Santamera 2008). However, public participation requirements for EIAs/SEAs are mostly limited to the scoping and review stage (UN Environment 2018). Moreover, problems with public participation are not new and, sometimes, public participation has been considered poor by a variety of authors because of well-known barriers in early and effective participation in EIA procedures (e.g. regulatory constraints, poor access to information, poor execution of participation methods, poor involvement of the public, excessive time and cost requirements, lack of transparency and a failure to influence the decision-making process) (Hartley and Wood 2005; Nadeem and Fischer 2011; Morgan 2012; Fuentes-Bargues 2014).

In practice, public participation is often reduced to an administrative formality to solve a requirement to offer potentially affected people information, instead of a substantive process to involve the public concerned in environmental decision-making (Shepherd and Bowler 1997; O’Faircheallaigh 2010). In addition, public participation is limited to holding consultations of technical documents and, sometimes, consultations can only be done by the public which is likely to be affected (known as ‘public concerned’ since the adoption of the amended Directive 2011/92/EU). Another very important aspect, in regards to the deficit of tradition in public participation, are inadequate deadlines and the fact that public participation occurs when the development of project options are not yet open. Indeed, the appropriate timing of public participation has much been debated in the literature (Hartley and Wood 2005; Nadeem and Fischer 2011). Therefore, real interaction between decision makers and the public is very limited or may even be absent in many sectors (Pardo 1997; Bond et al. 2004; Areizaga et al. 2012; Lindsay 2018), and one-definitional matter should be clarified in regards to the use of the term ‘public participation' (O’Faircheallaigh 2010; Glucker et al. 2013) which is usually used as a ‘catch all’ phrase without any critical examination (Mahoney et al. 2007). Nowadays, there is confusion regarding the methods that should be used to improve public participation and about which members of the public should be consulted (Hartley and Wood 2005; Ferreira et al. 2018). Nevertheless, a greater public participation in the Spanish EIA is demanded beyond its traditional narrow and minimalist translation of the EU legislation since the early 2000s (Palerm 1999; Fuentes-Bargues 2014).

This deficit of transparency at international levels is also more frequent than one imagines and the participation of the affected communities and other stakeholders usually results in a minimum element not only in HIA but also in health programmes (Kapiriri et al. 2003; Nieuwenhuijsen et al. 2017). This may be because of the lack of explicit benchmarks for the quality and quantity of participation, but practitioners also argue the very frequent limitation of time and resources to conduct their reports in a better way than those considered as a ‘desktop’ or ‘rapid’ approach (Schuchter et al. 2014). This contrasts strongly with the fact that citizen participation is recognized to be a fundamental requirement to legitimize decision-making not only in environmental matters (Nieuwenhuijsen et al. 2017; UN Environment 2018) but also in health policy and planning (Pagatpatan and Ward 2017; Littlejohns et al. 2019). In the health system, it is very common to demand channels of communication and, in this sense, different experiences are tested to reduce distances from formal and rhetorical participation to an active and real participation (Mahoney et al. 2007; Mira et al. 2018). Thus, further steps need to be taken in governance and an easy way to do so could be by making HIA reports freely available to the public as protection against unsatisfactory practices (Kemm 2007). Anyway, involving the public requires the allocation of adequate resources (Pagatpatan and Ward 2017).

4. The HIA follow-up: a real need

Follow-up is considered a crucial phase that needs to be undertaken for achieving overall effectiveness, not only in HIA but also in SEA and EIA (Sandín-Vázquez and Sarría-Santamera 2008; Gachechiladze-Bozhesku and Fischer 2012; Muir 2018). Their main missions include studying the causes why recommendations proposed after an HIA procedure could have been omitted, or the reasons why their effects may be different than expected in order to provide for feedback and learning (Boldo et al. 2005; Gachechiladze-Bozhesku and Fischer 2012). The Spanish Public Health Act 2011 (BOE 2011) establishes that results collected from HIA follow-up programs shall be integrated into the Public Health monitoring network. This is a network of surveillance which has to be implemented at a national level in order to serve as the basis for decision-making in case of non-communicable diseases and risk factors and determinants in order to achieve comprehensive public health surveillance in compliance with the same State law. In parallel, there is already an epidemiological surveillance Network. In this sense, EIA regulations can define two terms in order to separate monitoring tasks during both construction and operational project phases, but the presence of regulations does not necessarily guarantee that follow-up is actually implemented in practice (Morrison-Saunders et al. 2003). There are barriers common to several countries and there is current evidence of poor practice in many sectors (Morrison-Saunders et al. 2003; Jones and Fischer 2016). Despite researchers notice that follow-up programs in SEA or EIA should not be considered an option but a duty, because they have a valuable role to play in the development of good practices (Marshall 2005).

Follow-up was considered a weakness in EIA for many years and its implementation has been either lacking or very fragmented at the international level (Jalava et al. 2015). In practice, follow-up in SEA and EIA is still frequently not given sufficient attention and reasons for this historic deficit include the lack of fund and human resources, ineffective measures to ensure compliance and limited environmental awareness of many developers (Morrison-Saunders et al. 2003; Paliwal and Srivastava 2012). In addition, the fact that HIAs are not systematically undertaken causes a lack of studies using best-practice methodologies and a lack of baseline and impact data (Claudio et al. 2018). All this might have a negative impact on the credibility and the perception of the procedure’s usefulness by actors, an issue of major concern in the literature on HIA (Esnaola et al. 2010; Sanz et al. 2012; Vela-Ríos et al. 2016).

5. A last consideration on the scope of HIA and the lack of resources

Another controversial issue in any form of impact assessment is that it is usually funded and often also commissioned by the developer (Atkinson and Cooke 2005). There is also a growing worldwide interest in the costs and benefits of public health activities at national, regional and local levels which has been extended to HIA (Atkinson and Cooke 2005). This matter may lead practitioners to conduct low-cost HIAs which could appear to be desk-top exercises involving, for instance, minimal consultation with stakeholders instead of encouraging community. Anyway, the institutionalization of HIA requires greater resources in order to be systematically implemented (Ahmad 2004; Sanz et al. 2012; Schuchter 2014), as well as cooperation between sectors (Claudio et al. 2018), but it does not always work (Lee et al. 2013). It is obvious that there is a limitation in resources (human, financial and material), and that it is not possible to assess everything, so there is a need to make a rational use of the available resources and to apply prioritization criteria (Aldasoro et al. 2012).

In this sense, several authors have suggested that HIA is a cost-effective use of the National Health Service’s (NHS) resources (O’Reailly et al. 2006). Nevertheless, the benefits of HIA are often implicit, thus assessing and quantifying these benefits is challenging (Atkinson and Cooke 2005). This kind of controversy is not exclusive of the health sector and it remains very relevant from different points of view (Arce-Gomez et al. 2015; Jones et al. 2017; Mancini and Sala 2018). Indeed, there is a growing interest in the concept of integrated impact assessment (IIA) as a way to carry out a large number of studies regarding the multifaceted impact of projects, programs and policies (i.e. risk assessment, EIA, SEA, social impact assessment (SIA), and economic assessments) (Mindell and Joffe 2003; Dendena and Corsi 2015). It is also argued as a response to the need to rationalise and to avoid such a high number of impact assessments that may partially overlap (Birley 2003). Despite HIA not just being a component or variant of EIA (Cole and Fielding 2008), several authors have pointed to HIA as an optimal framework for inclusion of health into EIA and SEA procedures, although they were mainly focussed on physical, social and behavioural aspects of health (McCallum et al. 2018). On the contrary, it may be also considered that limiting HIA to the EIA process would miss many valuable opportunities for using HIA (Cole and Fielding 2008). On the other hand, there are not only differences between processes but the number of steps in the HIA process differs in some countries too (Hebert et al. 2012). In this regard, screening is the stage of the HIA process which allows to filter out proposals that do not require HIA (Mindell et al. 2003). Scoping is also crucial, because a failure in scoping may imply that unnecessary work will be undertaken or, on the contrary, that the significant consequences are missed (Snell and Cowell 2006). Thus, screening and scoping have budget implications. However, a justification of the level of evidence to scope an intervention is often conducted case by case and it cannot be statutorily established to what extent developers should delve into details.

In Spain, it is possible that regional and national governments may copy the model already developed in the case of Andalusia. Screening is determined by a list of projects from among those considered in the SEA and EIA legislation which have been selected as susceptible to being submitted to HIA, as happens, for instance, with Annex II of the new Directive 2014/52/EU (OJEU 2014) that amends the European Directive 2011/92/EU (OJEU 2011) on the assessment of the effects of certain public and private projects on the environment. In Andalusia, this was adopted in a legal text at the level of Law and, later, the list was incorporated as an Annex at a Legislative Decree level, which implies it will be adopted by the regional parliament and the regional government board, respectively. It is worth noting the inconvenience by the fact of linking the capacities of the Health Authorities to other sectorial norms (environmental in this case), whose rhythms and reasons for revision and updating may be completely unrelated to health and its determinants. The detailed definition of screening criteria in texts with the rank of Decree or Law can make it difficult to update them in accordance with the progress of knowledge and methods of assessment, due to the complexity of their own legal procedures and the different political circumstances. Indeed, dysfunctionalities can occur when environmental regulations are modified, due to the inclusion of activities with little impact on Public Health or vice versa. Furthermore, new evidences could also be discovered, regarding the potential risk of projects on human health or its determinants which may have been excluded from the SEA and/or EIA procedures.

In this case, it could be more useful to adopt regulatory developmental schemes, like those from sectors such as transport infrastructures that are continually subject to regulatory reviews. For instance, the Spanish Road Regulation (Royal Decree 1812/1994) includes a specific mention of the development of standards and technical instructions of lower rank than a law (article 29). In addition, it establishes that the competent Directorate in the matter (the Director of Roads) may approve the rules and instructions to which road projects will have to adjust, and they must be permanently updated (Figure 2). As a result, there are currently about 20 of the so-called Road Instructions (i.e. instructions for road trace design, vertical signalization, bridges, drainages, illumination, and so on) which, therefore, are official technical regulations. These instructions are mandatory in any road project and are edited and revised according to the needs that arise and are detected. That is, the competent body has an agile and flexible tool to adapt the technical regulations to the progress of technical and scientific knowledge, without the need to promote permanent changes at a political level, as is required when changing laws or decrees. In addition, this may be a way to give a response to the need for standardisation of procedures in order to improve effective consideration of health in plans and projects appraisal (Linzalone et al. 2019).

Figure 2. Example of hierarchical scheme of laws and technical regulations in the road sector in Spain.

Lastly, there is a final consideration to be pointed out in relation to workforce skills because expertise and capacity are still considered scarce and unevenly distributed not only in Spain but even at European level (Zambon and Martin-Olmedo 2019). The fact that a great effort is needed in capacity building to conduct HIAs in accordance with regulation and to further develop health in SEA and EIA should not be neglected (Vohra et al. 2016). Teaching and capacity building in EIA started in universities soon after it was institutionalized in the United States in the 1970s and, nowadays, EIA and SEA are taught at many universities around the world (Sánchez and Morrison-Saunders 2010). This is not the case regarding HIA in Spain today, despite the fact that implementation of HIA requires universities and public health schools to be involved in training programmes. In addition, its multidisciplinary nature will require training programmes on HIA to be included in different sectors (Esnaola et al. 2010). Also, a more extensive involvement of health professionals in health inclusion in SEA and EIA is needed (Fischer et al. 2010). In any case, there is a large variety of strategies (e.g. seminars, training courses, intersectoral working-groups, provision of adequate guidelines, easy access to completed HIAs, knowledge transfer and exchange on good practice, promotion of HIA and health in all policies) to deal with this challenge and provide capacity to current practitioners (Dannenberg et al. 2008; Schuchter et al. 2015).

6. Conclusions

This article seeks to contribute to the debate regarding HIA integration into SEA and EIA processes in three main ways:

There is a broader trend to consider that HIA integration into SEA and EIA procedures represents a tempting opportunity to reduce costs for both administrations and developers. Although for that to happen, a better foundation is required. It is known that both HIA and SEA/EIA require a minimum investment in resources to be effective and credible as well as the interdependence between human health and the components of the environment, analysed in a certain way in environmental assessments, which should not be ignored. However, cost and benefits of such integrations should be previously assessed.

On the other hand, the existence of well-known historical weaknesses in SEA and EIA procedures should not be perceived in a totally negative way, but rather as a brake on the immediate integration of HIA. In this sense, HIA could contribute to achieve better practices (e.g. in terms of public participation in EIA procedures). Therefore, it is considered appropriate to promote a previous and interdisciplinary debate in order to determine the real possibilities of integration of both disciplines, as well as to identify the needs of revision and/or adaptation of each of the procedures, their phases, methods and tools.

If integration of HIA into SEA and EIA, or convergence of procedures, has to be achieved, it would be preferable that the necessary regulatory and organizational reforms serve as a catalytic element, which would have a positive impact on the achievement of the specific, common objectives and principles of both SEA/EIA and HIA. In short, they are conceived to improve the population's health, as well as the assurance and improvement of the quality of the environment.

Conflict of interest

The authors declare that they have no competing interests.

Acknowledgments

Thanks are given to Rebeca López Gosling that kindly improved the English of the manuscript. Comments and suggestions raised by two anonymous referees have greatly improved this article.

Additional information

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.