The need for Health Impact Assessment
Screening the terms of reference of Swedish official government reports
NATIONAL INSTITUTE OF PUBLIC HEALTH
www.Jhi.se
HEALTH IMPACT ASSESSMENT 1 3
Introduction
In the Swedish public health policy, adopted by the Riksdag in April 2003, the government makes far-reaching commitments to "create societal conditions which ensure good health, on equal terms, for the entire population" (1). It is stated that successful public health efforts require initiatives in several policy areas and that this will require all public agencies and authorities whose operations and tasks affect public health to consider and report on the effects of their work on public health. In order to achieve this health impact assessment (HIA) is needed, which facilitates the systematic assessment of policies for health impacts in a population to ensure that the health consequences are not overlooked (2,3).
The public health bill contains eleven public health objective domains based on the main socio-economic, behavioural and environmental determinants of health covering both up-stream and down-stream determinants (Figure 1). The government emphasised the importance and need for further development of HIA as:
• The Swedish National Institute of Public Health (NIPH) should develop the HIA methodology, both nationally (in cooperation with the Swedish Association of Local Authorities and the Swedish Federation of County Councils) and internationally;
• The NIPH should identify policies of importance to public health and conduct relevant HIAs;
• The NIPH should use HIA in the monitoring and evaluation of the public health policy;
• There is a need for further investigation whether or not HIA is to be made statutory in Sweden as is the case for environmental impact assessment.
In response to these demands and as a follow-up of previous work on HIA by the NIPH (4), this report aims to develop and examine the screening phase in the HIA process by developing a checklist based on the new public health objective domains. Using this checklist, the terms of reference guiding Swedish government official reports from all ministries, from January 2001 to August 2002 were screened for potential health impacts.
14  HEALTH IMPACT ASSESSMENT
Overall aim:
"The creation of societal conditions which ensure good health, on equal terms, for the entire population ".
11 objective domains are prioritised and defined as follows: /. Participation and influence in society.
2. Economic and social security.
3. Secure and favourable conditions during childhood and adolescence.
4. Healthier working life.
5. Healthy and safe environments and products.
6. Health and medical care that more actively promotes good health.
7. Effective protection against communicable diseases.
8. Safe sexuality and good reproductive health.
9. Increased physical activity.
10. Good eating habits and safe food.
11. Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling.
Figure v The Swedish public health objective domains (i)
HEALTH IMPACT ASSESSMENT 1$
Aims and approaches of Health Impact Assessment (HIA)
There are several types of impact assessment including Health Impact Assessment (HIA), Environmental Impact Assessment (EIA), Social Impact Assessment (SIA), Human Impact Assessment (HuIA) and Integrated Impact Assessment (IIA). HIA is the only framework that exclusively covers health consequences. EIA covers mainly the environmental aspects but should also cover the health aspects; both SIA and Human IA include health consequences among other social issues (employment, income etc) and IIA covers economical, environmental and social issues. Currently, the most common way of assessing health impacts is to include HIA into an EIA, as EIA is already statutory in many countries. EIA is also statutory in the EU through directive 2001/42/EC, which explicitly includes aspects on human health. The aims of an HIA are (2,3):
• To improve knowledge about potential health impacts of a policy, programme or project;
• Inform decision-makers and affected populations about health impacts;
• Facilitate adjustment of the proposed policy or programme in order to mitigate the negative and maximise the positive health impacts, considering at the same time health equality aspects.
While many governments are already analysing the health impacts of major political decisions, the assessment is rarely systematic. HIA may be described as a systematic process which firstly examines how the policy proposal could affect the determinants of health and then analyses how the health determinants impact on population health. A quantitative HIA may be expressed in healthy life years lost (DALY) or other summary measures for the disease burden. This process is very similar to cost-effectiveness analysis of interventions, which rests on a non-financial metric design to allow comparisons across the health sector, usually expressed as cost per life year lost or gained (5). This combination of data, if available and evidence-based, provides policy-makers with the necessary information to make informed decisions concerning public health. As policies affect various sub-groups of the population differently, it is often necessary to analyse the health outcomes for each sub-group separately.
The eleven Swedish health objective domains, expressed as health determinants, facilitate the HIA process. During the process of developing these health determinants, both the evidence supporting their link to human health and some of the indicators needed to
l6  HEALTH IMPACT ASSESSMENT
measure them have been established (6). Future efforts need to address the qualitative and quantitative links between different policies, programmes or projects and health determinants (4), where our knowledge is rather limited.
HEALTH IMPACT ASSESSMENT 1~J
The HIA process
Figures 2 illustrates a framework for HIA, which has been adapted to the Swedish situation with a politically approved public health policy based on a range of health determinants. This model represents a further development of the model developed at the Goteborg consensus meeting in 1999 (3,4).
Identifying Apprasial Results Recommendations
potential methods health effects
New _ Screening
proposals On the
basis of the national public
Existing _ health
policy objectives
Health impact review
Impact on	-►
•Health	
determinants	
•Health	
outcomes	
Opinions	
of those	
involved	
Proposal approved
Proposal rejected and reformulated
Monitoring &. Evalution
Knowledge base of HIA Effects on health determinants, health outcomes and distribution of effects
Figure 2. The Swedish framework model of HIA (4).
The HIA process usually follows five stages: Screening, scoping, appraisal, formulation of recommendations and evaluation and monitoring. These stages should not be seen as completely separate entities. Depending on how detailed each phase is performed some overlap may occur. During all stages of the procedure the knowledge base of HIA should be used to inform the process.
The first phase in the HIA process requires the decision of which documents to screen. This phase also necessitates identification of the linkages between the policy proposals and health determinants, the least elucidated part of HIA. The documents to be screened should be available early in the political process for the assessment to have an impact on the final decision-making.
l8   HEALTH IMPACT ASSESSMENT
In the scoping stage, the scale of the appraisal is decided upon including a judgement on resource allocation. An important factor in this decision is whether the proposal affects the whole population or subgroups and the magnitude of the potential effects. The appraisal methods available are in-depth analysis, a rapid health impact analysis or a health impact review. A rapid analysis, done in a couple of days, is a systematic review of the potential health impacts of the proposal, carried out by a number of experts, decision-makers and representatives of potentially affected population groups. The in-depth analysis includes a synthesis of the available evidence, exploration of options, experience and expectations of those who may be affected and if required, production and analysis of new data. Such an analysis would usually include a broad range of multidisciplinary expertise and a combination of methodologies. Assessing whole policies for health impacts, e.g. agriculture policy, may require a health impact review which aims to create a convincing summary estimate of the most significant impacts on health, without necessarily trying to disentangle each single impact of specific sections of the policy. Such a review should be carried out by multidisciplinary experts and is a time consuming exercise.
Evaluation of the HIA-process and the outcomes is important knowledge which should be fed back into the knowledge base of HI A in order to inform future HI As.