As individuals, we tend to consider all of consequences before we make an important decision. When we buy a car, for example, we consider how much we want to spend, where we plan to drive, who we plan to transport, how much money it might cost to maintain, how much gas it will use, and whether we like to drive it. If you’re like me, you may even create a spreadsheet to record all of the factors and relevant data points that help you decide which car best is the best choice.
Similarly, when policymakers decide on a course of action, they hopefully examine all aspects of a proposal. In fact, laws mandate policymakers to consider certain types of impacts stemming from government actions. For example, the National Environmental Policy Act (NEPA) mandates that the federal government considers the environmental effects of major projects and policies that involve federal funds in the form of an Environmental Impact Statement (EIS).
A similar tool exists for policymakers to consider the impacts of a proposed policy to community and individual health: a Health Impact Assessment (HIA). An HIA is a process that uses a wide variety of data to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects among the population. As the California Department of Public Health stated, the goal of an HIA is “to make visible the potentially significant human health consequences of public decisions and thus to facilitate the greater consideration of health in policy decisions.”
An HIA has six steps: (1) screening, where stakeholders decide whether an HIA is needed; (2) scoping, where decision makers make a plan for the HIA; (3) assessment, where the baseline health of affected communities is described and potential impacts are assessed; (4) recommendations, where policymakers develop solutions; (5) reporting, where policymakers disseminate the findings to decision makers; and (6) monitoring and evaluation, where the efficacy of the implemented policies are evaluated. Importantly, the larger community remains involved throughout the entire HIA process.
Using HIAs to evaluate project proposals has a number of benefits. First, the HIA uses a participatory approach that pools expertise from a variety of fields and from the broader community. Second, studies show that using HIAs improve health and reduce inequality. Third, HIAs are appropriate for projects of many different sizes and in many different sectors. Finally, HIAs promote sustainable development, making them especially important in lessdeveloped areas of the world.
HIAs are embraced around the world as a way to make better decisions that impact human health. The World Health Organization has been promoting the use of HIAs for over 20 years. Governments in Quebec, Thailand, South Australia, the United Kingdom, the Netherlands, and New Zealand require the use of HIAs in policymaking. HIAs are also more commonly required in large development projects, such as those funded through the International Finance Corporation, a part of the World Bank.
There is no federal mandate and very little federal funding for the use of HIAs in policymaking in the United States. The CDC’s Health Community Design Initiative is the only source of federal support for using HIAs in states and local communities. Several states recommend but don’t require them. Although no states currently require the use of HIAs in decisionmaking, there are several examples of projects that were influenced by the data uncovered through an HIA process, including: Alaska’s HIA Program has examined the effects of oil and gas development projects, the Florida development authority accepted HIA recommendations when deciding whether to build a new coal-fired power plant, and the results of an HIA were used in Minneapolis to get funding for pedestrian and bicycle improvements in a low-income urban corridor.
Over the last few years, state and federal legislators have sponsored bills to mandate HIAs. For example, in 2006, Senators Obama, Durbin, Clinton, and Kerry proposed the Federal Healthy Places Act, which would have required federal agencies to support HIAs and to take other actions to improve health and environmental qualities of communities.
Absent governmental support of HIAs, several non-profit organizations promote the use of HIAs through education and grants to local and state governments to utilize HIAs in their policymaking. The Health Impact Project is one such organization, which provides funding for HIAs and even maintains a database of HIAs in the United States.
As two commentators in the Journal of the American Medical Association wrote in 2009, “Health is determined not only by genetics and personal choices but also by policies and environmental factors.” Given our recognition that a number of factors contribute to human health, governments and foundations in the United States ought to recognize the value of HIAs as a way of incorporating public health expertise into policy decisions.