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The need for health impact assessment in China: Potential benefits for public health and steps forward
Environmental Impact Assessment Review 31 (2011) 420–424
Contents lists available at ScienceDirect
Environmental Impact Assessment Review j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e i a r
The need for health impact assessment in China: Potential benefits for public health and steps forward Liming Wu a,b,⁎, Shannon Rutherford b, Cordia Chu b a b
Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, China Center for Environment and Population Health, Griffith University, Nathan 4111, Australia
a r t i c l e
i n f o
Available online 24 April 2010 Keywords: China Population health challenges Health impact assessment
a b s t r a c t Health impact assessment (HIA) is a useful tool to predict and estimate the potential health impact associated with programs, projects, and policies by comprehensively identifying relevant health determinants and their consequences. China is undergoing massive and rapid socio-economic changes leading to environment and population health challenges such as a large increase in non-communicable diseases, the emergence and reemergence of infectious diseases, new health risks associated with environmental pollutants and escalating health inequality. These health issues are affected by multiple determinants which can be influenced by planned policies, programs, and projects. This paper discusses the needs for health impact assessment in China in order to minimize the negative health consequences from projects, programs and policies associated with rapid social and economic development. It first describes the scope of China's current impact assessment system and points out its inadequacy in meeting the requirements of population health protection and promotion. It then analyses the potential use of HIA and why China needs to develop and apply HIA as a tool to identify potential health impacts of proposed programs, projects and policies so as to influence decision-making early in the planning process. Thus, the paper recommends the development of HIA as a useful tool in China to enhance decision-making for the protection and promotion of population health. For this to happen, the paper outlines steps necessary for the establishment and successful implementation of HIA in China: beginning with the establishment of a HIA framework, followed by workforce capacity building, methodology design, and intersectoral collaboration and stakeholder engagement. Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved.
1. Introduction China is one of the world's fastest growing economies, experiencing rapid modernization, industrialization and urbanization. This phenomenal economic development also leads to rapid environmental, social and lifestyle changes and their associated health risks. Indeed, China is facing immense population health challenges ranging from a large increase in non-communicable diseases such as stroke, cancer and cardiovascular diseases (Ministry of Health of China, 2009), to the emergence and re-emergence of infectious diseases such as HIV/AIDs and TB, to new health risks associated with environmental pollution and industrial development. In addition, health inequality in China is a growing problem, particularly between rural and urban populations (Ministry of Health of China, 2009; Wang, 2005). China's rapid development and its associated serious environment and population health threats require a shift in population health response. New strategies such as health impact assessment (HIA) are required to address and manage the many and interconnected ⁎ Corresponding author. Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, China. E-mail address: [email protected] (L. Wu).
environmental, social, demographic, cultural and biological determinants underpinning the contemporary population health problems such as exposure to unsafe environments (pollution, poor design of the built environment, workplace hazards, unsafe products, etc), access to health services, social inequity, lifestyle and consumption patterns. This paper argues that HIA is potentially a useful tool to enhance decision-making regarding policies, projects and programs impacting on or addressing population health issues. It will first describe the scope of China's current impact assessment system and analyse the potential use of HIA within this existing system. The second part of the paper will make recommendations for the work required should a HIA framework be developed and introduced into decision-making processes in China. 2. Background Impact assessment methodologies have been demonstrated to be an effective tool for predicting and estimating the influence of projects, programs, and policies (International Association for Impact Assessment, 2008). Environmental Impact Assessment has been used in much of the developing world since the 1970s (Glasson et al., 2005). The relatively recent emergence of HIA reflects the increasing need to improve the assessment of health impacts of policies, projects
0195-9255/$ – see front matter. Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.eiar.2010.03.004
L. Wu et al. / Environmental Impact Assessment Review 31 (2011) 420–424
and programs and in doing so, consider the breadth of health determinants: including the social, environmental, cultural and political influences on population health (Naidoo and Wills, 2000; U.S. Department of Health and Human Services, 2000). HIA is defined as “A combination of procedures, methods and tools by which a policy, program or project may be assessed and judged for its potential effects on the health of the population and the distribution of these impacts within the population” by World Health Organization (WHO) (WHO Regional Office for Europe and European Center for Health Policy, 1999). It has been used in a number of countries and applied to a range of activities and has been shown to be a useful tool for enhancing decision-making (Birley, 2004; Lock et al., 2003; Nam Theun 2 power company, 2007; Thackway et al., 2005). HIA is a comprehensive tool useful to facilitate a systematic and transparent consideration of the potential health impacts of projects, policies and programs, underpinned by principles of health equity, sustainability, community engagement, transparency and health promotion. The key features of HIA that make it a useful tool worthy of exploring include its comprehensive consideration of the determinants of health, explicit consideration of both negative and positive influences on population health, and integrative analysis of impacts utilizing quantitative and qualitative methods. HIA, as a methodological approach, is relatively unknown in China, even though it has been recognized as a useful and systematic method that is increasingly being used around the world to assist in decisionmaking processes for projects, programs and policy (Morgan, 2003; WHO Regional Office for Europe and European Center for Health Policy, 1999), In China, very few government health officials or academics are familiar with it as a concept and even fewer, advocate for its application. This paper argues that in view of the serious population health challenges that China is facing and will face into the future, HIA has great potential to assist Chinese decision-makers to protect and promote health in view of the inadequacy of the current impact assessment system to deal with health issues.
3. China's current impact assessment system EIA is the most complete and comprehensively applied impact assessment approach in China. Due to the concern for environmental pollution associated with industrial development, a pilot Environmental Protection Act was introduced in 1979. Following the initial pilot Act, a series of amendments, regulations and technical guidelines were published (Ministry of Environmental Protection of China, 2008; Zhou and Wang, 2008) (Refer to Table 1). The current EIA system in
421
China has the following major characteristics: (1) The formal steps of the EIA process in China are consistent with standard EIA methodology (Glasson et al., 2005; Thomas and Elliott, 2005). (2) The EIA process in China is mainly applied to predict and evaluate the environmental influences of construction programs and projects. The Environmental Impact Assessment Act (2002) increases the scope of EIA to limited regional land use planning policies and development policies, but maintains a strong environmental focus. So far, few policy-related EIA projects had been conducted in China. (3) Generally, the EIA system in China is focused on physical environmental impacts. However, in the 2008 draft of the Technical Guideline for Environmental Impact Assessment on Human Health, health impacts, as well as environmental impacts, are considered as an important assessment objective. In this draft guideline, a health impact is defined as an effect of the physical environmental factors, which may be estimated by a health risk assessment. China does not have any social impact assessment legislation or guidelines and the EIA legislation does not include a requirement for social impacts. Hence, the implementation of SIA in China is very limited and is still in the exploratory stage. Due to the rapid growth in industrial development and the increasing prevalence of occupational diseases, China established a process called Pre-assessment of Occupational Hazard in Construction Project (PaOHCP) in the early 2000s to prevent occupational diseases and promote occupational health. PaOHCP is driven by the Law on the Prevention and Treatment of Occupational Diseases (2002). PaOHCP involves predicting and estimating the potential occupational health impacts and is required prior to the implementation of construction projects and programs as a compulsory component of the official approval process as well as EIA. The important characteristics of PaOHCP are: • Though the steps of the process differ in terminology, they are conceptually similar to those of EIA. • It focuses on negative health impacts of occupational diseases hazards in workers. • It is implemented to predict and evaluate the health influences of construction programs and projects, and is not suitable for the assessment of policies. • It is prospective, acting as a tool to predict and estimate the occupational health impacts of construction projects and programs before they are implemented. • It mainly considers the chemical, physical, radioactive, and biological factors according to the guideline document classification for the risk factors.
Table 1 The history of EIA in China. Date
Legislation or guidelines
Provisions
1979
Environmental Protection Act (pilot)
1986
Environmental Protection Management Measure for Construction Projects Environmental Protection Act
Firstly requires EIA as a compulsory component of official approval for predicting and estimating the environmental impacts before the implementation of construction programs and projects, and identify the decision-maker Regulates the screening and scoping processes of EIA and the content of EIS, and identify the decision-maker Replaces the pilot Act, and formally requires EIA as a compulsory component of the official approval to predict and estimate the environmental impacts before the implementation of construction programs and projects, and identify the decision-maker Provides detailed explanations of the steps and requirements of EIA: screening, scoping, assessment, mitigation, and decision-making; and regulates the content of EIA Emphasizes the screening, scoping, and following-up processes of EIA, and identifies the decision-maker Focuses on how to implement EIA besides construction projects and programs, firstly requires EIA to predict and evaluate the environmental impacts of policies, especially planning and developing policies; it identifies the decision-maker and advocates community participation Highlights the environmental health impact of projects, programs, and policies; and introduces HRA as the assessment method
1989
1994 1998 2002
2008
Technical Guideline for Environmental Impact Assessment Environmental Protection Management Regulation for Construction Projects Environmental Impact Assessment Act
Technical Guideline for Environmental Impact Assessment on Human Health (draft)
422
L. Wu et al. / Environmental Impact Assessment Review 31 (2011) 420–424
The arguments for strengthening China's IA system through inclusion of HIA to better assist in population health decision-making can be summarized as follows:
4. The utility of HIA in China The key characteristics of the two current assessment approaches and those of HIA are summarized in Table 2 to allow for comparison. Based on Table 2, the following observations can be made about the current IA system and the utility of HIA for China.
1. The current systems used in China are primarily focused on physical environmental determinants of health and hence are limited in their assessment of the breadth of population health determinants. How social and other non-environmental determinants of general population's health influence health is a major assessment gap in the current IA system in China. For assisting in decision-making relating to population health, HIA has been demonstrated to be a useful and comprehensive tool. 2. The PaOHCP and EIA systems in China have specific and limited assessment objectives. Theoretically HIA as a concept has potential to be applied more broadly to projects, programs or policies. It has been used to assist decision-making across these three activities in many places in the world (Birley, 2004; Dora and Racioppi, 2003; Harris et al., 2007; Lock et al., 2003; Thackway et al., 2005). 3. Compared with PaOHCP and Chinese EIA, HIA not only concentrates on negative impacts, but also positive impacts making recommendations that ensure that positive aspects are enhanced and negative aspects are minimized. For example, recommendations may be made to reduce negative impacts such as reducing air pollution from a new industrial activity and enhance positive impacts such as increasing access to green space in a residential development. Hence HIA can play a significant role in both health promotion and protection. This is particularly important in helping to address issues related to non-communicable (lifestyle) related diseases such as diabetes and cardiovascular disease which are increasing in prevalence in China. 4. One of the important applications of HIA is for addressing health inequality. Health inequality is a challenging issue in public health, which can be effectively addressed by “intersectoral” policies (Mackenbach et al., 2004; Wright et al., 2005). As WHO described, HIA is a tool to identify the distribution of impacts within a population (WHO Regional Office for Europe and European Center for Health Policy, 1999), such as the inequitable distribution of occupational disease in workers in China, where migrant workers suffer from higher rates of occupational injury and disease (Han et al., 2006; Li and Wu, 2008; Xiao, 2007; Yu, 2008). Underpinning the effective use of HIA is multi-sectoral collaboration through identification and analysis of determinants of health. None of the current IA approaches used in China explicitly consider this critical issue of health inequality.
4.1 Assessment objectives HIA as a tool can be applied to broad assessment objectives, including projects, programs, and policies. The focus of PaOHCP is for construction projects and programs and though the Chinese EIA includes application to policy (as well as projects and program), its current application is generally limited to land planning and few development-related policies. Therefore, general policy and nonconstruction projects and programs are blind spots for the current IA system in China. 4.2 Target and breadth of assessment HIA is generally targeted at population health promotion and protection with comprehensive consideration of multiple determinants of health. Though PaOHCP only focuses on occupational health impacts on workers, the draft of the Chinese EIA technical guidelines includes consideration of health for the general population as well as the environment. However both systems are generally most focused on the physical environmental determinants that influence health. 4.3 Focus of effect of impact In contrast to Chinese EIA and PaOHCP systems which are primarily focused on identifying negative impacts, explicit to HIA methodology is the consideration of both negative and positive health impacts. 4.4 Assessment methods HIA utilizes both quantitative and qualitative methods, partly reflecting the strong role of community and other stakeholder engagement underpinning HIA and the consideration of a breadth of health determinants. PaOHCP and EIA in China most commonly use quantitative methods to collect data and evaluate health impacts.
Table 2 A comparison of Chinese EIA and PaOHCP and HIA. Items
Chinese EIA
Chinese PaOHCP
HIA
Assessment objectives
Policy (land planning and developing), program, and Project Screening Scoping Assessment Decision-making Mitigation Follow-up Quantitative Negative General population and environment
Construction projects and programs
Any project, program, and policy
Screening Scoping Assessment Decision-making Recommendation Monitoring Quantitative Negative Occupational groups
Screening Scoping Assessment Decision-making Recommendation Monitoring Mixed methods: quantitative and qualitative Positive and negative General population
– √
– √
√ √
– – –
– – –
√ √ √
Steps
Assessment methods Focus of effect of impact Target and breadth of assessment Determinants considered Individual Physical environmental (including chemical, physical, radioactive, and biological) Social Cultural Accessibility of health services
L. Wu et al. / Environmental Impact Assessment Review 31 (2011) 420–424
5. Recommendations for the future development of HIA in China Section 4 established that HIA would significantly enhance China's impact assessment system, filling many of the gaps identified in the existing system. International experience suggests that there are six key factors necessary for successful application of HIA. They include intersectoral communication and collaboration, comprehensive stakeholder participation, scientific and conditional scoping, adequate HIA process training, holistic concept of health for HIA practitioners, and emphasis on the positive and negative outcomes (Lock and McKee, 2005). For the successful application of HIA in China, first a HIA framework needs to be developed by the health department. Such a framework should include guidelines for application and consideration of how HIA can best be implemented in the Chinese government decision-making context and existing impact assessment system with consideration given to issues such as the identity and role of the executive agency of HIA projects; the role and participation of other agencies, organizations, and communities; the scope of application; and the type of framework, legislative or otherwise, that could be best developed to ensure the use of HIA in decision-making. If commitment to HIA is progressed then other areas of work relating to workforce capacity, methodology and information and intersectoral collaboration and stakeholder participation need to be developed. 5.1 Building HIA workforce capacity WHO has identified that lack of HIA professionals is a major barrier for the implementation of HIA (Caussy et al., 2003). Hence, it is important to train a group of public health practitioners in the HIA methodology in the initial stage. They can provide leadership to others and undertake the implementation of early HIA projects. As HIA requires collaboration and participation between different departments and organizations in order to effectively assess multiple health determinants, it is important to develop a broad knowledge of health in personnel from other agencies involved in HIA. Such professional development can improve the understanding of HIA and better facilitate intersectoral collaboration and community participation (Dannenberg et al., 2006). 5.2 Developing the HIA methodology In order to best assist decision-making, HIA relies on a comprehensive understanding of the relationship between determinants and health impacts within the project, policy, program being assessed. Unlike traditional methods of assessment such as Health Risk Assessment, HIA also incorporates social determinants and has a strong emphasis on community engagement during the assessment process. Hence both quantitative and qualitative methods are commonly used in the data collection and assessment stages of HIA. However, qualitative data are not commonly utilized in the Chinese impact assessment system and useful, newer quantitative methods such as analysis of spatial data are still underutilized. 5.3 Improving intersectoral collaboration and stakeholder participation HIA focuses on various health determinants, and many departments or organizations (other than Health) have a better access and understanding of data related to these determinants. Therefore, intersectoral collaboration is required to assess the breadth of potential impacts and create the multi-approach solutions to deal with them. Stakeholder participation not only refers to the involvement of departments and organizations, but also includes the participation of other groups like experts and the wider community to increase the reliability of qualitative assessment and facilitate
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finding solutions. To ensure HIA is used most efficiently, specific strategies need to be developed to create a more collaborative environment and to encourage full stakeholder engagement (Chu, 1994; World Health Organization, 1986, 1997). Then, if utilized effectively, the application of HIA itself will strengthen collaboration and improve stakeholder engagement, leading to more sustained partnerships. 6. Conclusion China is experiencing rapid environment and lifestyle changes associated with phenomenal socio-economic development. These developments also bring with them many new population health challenges such as the increase in non-communicable diseases and health inequality, greater exposure to unsafe environments and products, and faster and large-scale transmission of infectious diseases. These pressing challenges stem from the many interacting determinants and require comprehensive assessment tools to enhance decisionmaking in the design and planning phase. The usefulness of HIA has been demonstrated in many countries but not yet in China where current EIA and PaOHCP processes are not designed to adequately assess the broad population health impacts related to the implementation of projects, programs, and policies. In this context, this paper argues that in order to better protect and promote population health, China needs to develop HIA as a tool to systematically estimate and predict the health impacts in the planning process prior to the commencement of programs, projects and policies. The paper concludes by recommending future steps for the establishment and implementation success of HIA in China involving the design of a HIA framework, workforce capacity building, design of methodology, intersectoral collaboration and stakeholder engagement. References Birley M. HIA in developing countries. In: Kemm J, Parry J, Palmer S, editors. Health impact assessment: concept, theory, techniques, and applications. New York: Oxford University Press Inc.; 2004. Caussy D, Kumar P, Sein UT. Health impact assessment needs in south-east Asian countries. Bull World Health Organ 2003;81(6):439–43. Chu C. Integrated health and environment: the key to an ecological public health. In: Chu C, Simpson R, editors. Ecological public health: from vision to practice. Nathan: Griffith University & Center for Health Promotion; 1994. p. 1-10. Dannenberg A, Bhatia R, Cole BL, Dora C, Fielding JE, Kraft K, et al. Growing the field of health impact assessment in the United States: an agenda for research and practice. Am J Public Health 2006;96:262–70. Dora C, Racioppi F. Including health in transport policy agendas: the role of health impact assessment analyses and procedures in the European experience. Bull World Health Organ 2003;81:399–403. Glasson J, Therivel R, Chadwick A. In: Glasson J, editor. Introduction to environmental impact assessment. 3 ed. London: Routledge; 2005. Han YZ, Wang ZB, Gu MH, Wu JZ. The occupational hazards affecting farmer-workers in China. J Occup Environ Med 2006;23(3):285–7. Harris P, Harris-Roxas B, Harris E, Kemp L. Health impact assessment: a practical guide. Sydney: Center for Health Equity Training, Research and Evaluation; 2007. International Association for Impact Assessment. About IAIA. [Internet]. Fargo: International Association for Impact Assessment; 2008 [cited 2008 April 28]. Available from: http://www.iaia.org/modx/index.php?id=318. Li MQ, Wu CR. The prevention and control on occupational diseases of the migrant workers. Mod Prev Med 2008;35(3):446–7. Lock K, McKee M. Health impact assessment: assessing opportunities and barriers to intersectoral health improvement in an expanded European Union. J Epidemiol Community Health 2005;59:356–60. Lock K, Gabrijelcic-Blenkus M, Martuzzi M, Otorepec P, Wallace P, Dora C, et al. Health impact assessment of agriculture and food policies: lessons learnt from the Republic of Slovenia. Bull World Health Organ 2003;81(6):391–8. Mackenbach JP, Veerman LV, Barendregt JJ, Kunst AE. Health inequalities and HIA. In: Kemm J, Parry J, Palmer S, editors. Health impact assessment: concept, theory, techniques, and applications. New York: Oxford University Press Inc.; 2004. Ministry of Environmental Protection of China. Technical Guideline for Environmental Impact Assessment on Human Health (draft). [Internet]. Beijing: Ministry of Environmental Protection of China; 2008 [cited 2008 May 10]. Available from: http: //www.mep.gov.cn/info/bgw/bbgth/200804/W020080407518392493258.pdf. Ministry of Health of China. The statistical bulletin of public health development in China, 2008. [Internet]. Beijing: Ministry of Health of China; 2009 [cited 2009 September 11]. Available from: http://www.moh.gov.cn/publicfiles/business/ htmlfiles/mohwsbwstjxxzx/s8208/200904/40250.htm.
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Morgan RK. Health impact assessment: the wider context. Bull World Health Organ 2003;81(6):390. Naidoo J, Wills J. Health promotion: foundations for practice. 2 ed. London: Bailliere Tindall; 2000. Nam Theun 2 power company. Health impact assessment and public health action plan. [Internet]. Vientiane: Nam Theun 2 power company; 2007 [cited 2008 May 28]. Available from: http://www.namtheun2.com/gallery/libr_sdp/newversion/Volume% 201/Chapter%205%20Health%20Resettler%20Regional%20cf.pdf. Thackway S, Furber S, Neville L. Health impact assessment case study: working with local government to obtain health benefits. NSW Public Health Bull 2005;16(7–8):127–8. Thomas I, Elliott M. Environmental impact assessment in Australia: theory and practice. 4 ed. Sydney: The Federation Press; 2005. U.S. Department of Health and Human Services. Healthy people 2010: Understanding and improving health. Washington DC: U.S. Department of Health and Human Services; 2000. Wang YZ. China's hygiene problems and health justice during the transition period. Chin Ind Econ 2005;12:56–63.
WHO Regional Office for Europe, European Center for Health Policy. Health impact assessment: main concepts and suggested approach. Brussels: European Center for Health Policy; 1999. World Health Organization. Ottawa charter for health promotion; 1986. World Health Organization. Jakarta Declaration on leading health promotion into the 21st century. [Internet]. Geneva: World Health Organization; 1997 [cited 2008 May 4]. Available from: www.who.int/hpr/NPH/docs/jakarta_declaration_en.pdf. Wright J, Parry J, Mathers J. Participation in health impact assessment: objectives, methods and core values. Bull World Health Organ 2005;83:58–63. Xiao YL. The hazards on occupational diseases of the migrant worker should be emphasized. Chin J Ind Med 2007;20(6):389–90. Yu JY. The brief discussion on the origin and countermeasure on occupational injury of the migrant workers. J JiangXi Univ Finance Econ 2008(4):55–9. Zhou XH, Wang Y. Characteristic and development tendency on system of environmental impact assessment in China. Energy Environ Prot 2008;22(11–14).
Contents lists available at ScienceDirect
Environmental Impact Assessment Review j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e i a r
The need for health impact assessment in China: Potential benefits for public health and steps forward Liming Wu a,b,⁎, Shannon Rutherford b, Cordia Chu b a b
Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, China Center for Environment and Population Health, Griffith University, Nathan 4111, Australia
a r t i c l e
i n f o
Available online 24 April 2010 Keywords: China Population health challenges Health impact assessment
a b s t r a c t Health impact assessment (HIA) is a useful tool to predict and estimate the potential health impact associated with programs, projects, and policies by comprehensively identifying relevant health determinants and their consequences. China is undergoing massive and rapid socio-economic changes leading to environment and population health challenges such as a large increase in non-communicable diseases, the emergence and reemergence of infectious diseases, new health risks associated with environmental pollutants and escalating health inequality. These health issues are affected by multiple determinants which can be influenced by planned policies, programs, and projects. This paper discusses the needs for health impact assessment in China in order to minimize the negative health consequences from projects, programs and policies associated with rapid social and economic development. It first describes the scope of China's current impact assessment system and points out its inadequacy in meeting the requirements of population health protection and promotion. It then analyses the potential use of HIA and why China needs to develop and apply HIA as a tool to identify potential health impacts of proposed programs, projects and policies so as to influence decision-making early in the planning process. Thus, the paper recommends the development of HIA as a useful tool in China to enhance decision-making for the protection and promotion of population health. For this to happen, the paper outlines steps necessary for the establishment and successful implementation of HIA in China: beginning with the establishment of a HIA framework, followed by workforce capacity building, methodology design, and intersectoral collaboration and stakeholder engagement. Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved.
1. Introduction China is one of the world's fastest growing economies, experiencing rapid modernization, industrialization and urbanization. This phenomenal economic development also leads to rapid environmental, social and lifestyle changes and their associated health risks. Indeed, China is facing immense population health challenges ranging from a large increase in non-communicable diseases such as stroke, cancer and cardiovascular diseases (Ministry of Health of China, 2009), to the emergence and re-emergence of infectious diseases such as HIV/AIDs and TB, to new health risks associated with environmental pollution and industrial development. In addition, health inequality in China is a growing problem, particularly between rural and urban populations (Ministry of Health of China, 2009; Wang, 2005). China's rapid development and its associated serious environment and population health threats require a shift in population health response. New strategies such as health impact assessment (HIA) are required to address and manage the many and interconnected ⁎ Corresponding author. Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, China. E-mail address: [email protected] (L. Wu).
environmental, social, demographic, cultural and biological determinants underpinning the contemporary population health problems such as exposure to unsafe environments (pollution, poor design of the built environment, workplace hazards, unsafe products, etc), access to health services, social inequity, lifestyle and consumption patterns. This paper argues that HIA is potentially a useful tool to enhance decision-making regarding policies, projects and programs impacting on or addressing population health issues. It will first describe the scope of China's current impact assessment system and analyse the potential use of HIA within this existing system. The second part of the paper will make recommendations for the work required should a HIA framework be developed and introduced into decision-making processes in China. 2. Background Impact assessment methodologies have been demonstrated to be an effective tool for predicting and estimating the influence of projects, programs, and policies (International Association for Impact Assessment, 2008). Environmental Impact Assessment has been used in much of the developing world since the 1970s (Glasson et al., 2005). The relatively recent emergence of HIA reflects the increasing need to improve the assessment of health impacts of policies, projects
0195-9255/$ – see front matter. Crown Copyright © 2010 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.eiar.2010.03.004
L. Wu et al. / Environmental Impact Assessment Review 31 (2011) 420–424
and programs and in doing so, consider the breadth of health determinants: including the social, environmental, cultural and political influences on population health (Naidoo and Wills, 2000; U.S. Department of Health and Human Services, 2000). HIA is defined as “A combination of procedures, methods and tools by which a policy, program or project may be assessed and judged for its potential effects on the health of the population and the distribution of these impacts within the population” by World Health Organization (WHO) (WHO Regional Office for Europe and European Center for Health Policy, 1999). It has been used in a number of countries and applied to a range of activities and has been shown to be a useful tool for enhancing decision-making (Birley, 2004; Lock et al., 2003; Nam Theun 2 power company, 2007; Thackway et al., 2005). HIA is a comprehensive tool useful to facilitate a systematic and transparent consideration of the potential health impacts of projects, policies and programs, underpinned by principles of health equity, sustainability, community engagement, transparency and health promotion. The key features of HIA that make it a useful tool worthy of exploring include its comprehensive consideration of the determinants of health, explicit consideration of both negative and positive influences on population health, and integrative analysis of impacts utilizing quantitative and qualitative methods. HIA, as a methodological approach, is relatively unknown in China, even though it has been recognized as a useful and systematic method that is increasingly being used around the world to assist in decisionmaking processes for projects, programs and policy (Morgan, 2003; WHO Regional Office for Europe and European Center for Health Policy, 1999), In China, very few government health officials or academics are familiar with it as a concept and even fewer, advocate for its application. This paper argues that in view of the serious population health challenges that China is facing and will face into the future, HIA has great potential to assist Chinese decision-makers to protect and promote health in view of the inadequacy of the current impact assessment system to deal with health issues.
3. China's current impact assessment system EIA is the most complete and comprehensively applied impact assessment approach in China. Due to the concern for environmental pollution associated with industrial development, a pilot Environmental Protection Act was introduced in 1979. Following the initial pilot Act, a series of amendments, regulations and technical guidelines were published (Ministry of Environmental Protection of China, 2008; Zhou and Wang, 2008) (Refer to Table 1). The current EIA system in
421
China has the following major characteristics: (1) The formal steps of the EIA process in China are consistent with standard EIA methodology (Glasson et al., 2005; Thomas and Elliott, 2005). (2) The EIA process in China is mainly applied to predict and evaluate the environmental influences of construction programs and projects. The Environmental Impact Assessment Act (2002) increases the scope of EIA to limited regional land use planning policies and development policies, but maintains a strong environmental focus. So far, few policy-related EIA projects had been conducted in China. (3) Generally, the EIA system in China is focused on physical environmental impacts. However, in the 2008 draft of the Technical Guideline for Environmental Impact Assessment on Human Health, health impacts, as well as environmental impacts, are considered as an important assessment objective. In this draft guideline, a health impact is defined as an effect of the physical environmental factors, which may be estimated by a health risk assessment. China does not have any social impact assessment legislation or guidelines and the EIA legislation does not include a requirement for social impacts. Hence, the implementation of SIA in China is very limited and is still in the exploratory stage. Due to the rapid growth in industrial development and the increasing prevalence of occupational diseases, China established a process called Pre-assessment of Occupational Hazard in Construction Project (PaOHCP) in the early 2000s to prevent occupational diseases and promote occupational health. PaOHCP is driven by the Law on the Prevention and Treatment of Occupational Diseases (2002). PaOHCP involves predicting and estimating the potential occupational health impacts and is required prior to the implementation of construction projects and programs as a compulsory component of the official approval process as well as EIA. The important characteristics of PaOHCP are: • Though the steps of the process differ in terminology, they are conceptually similar to those of EIA. • It focuses on negative health impacts of occupational diseases hazards in workers. • It is implemented to predict and evaluate the health influences of construction programs and projects, and is not suitable for the assessment of policies. • It is prospective, acting as a tool to predict and estimate the occupational health impacts of construction projects and programs before they are implemented. • It mainly considers the chemical, physical, radioactive, and biological factors according to the guideline document classification for the risk factors.
Table 1 The history of EIA in China. Date
Legislation or guidelines
Provisions
1979
Environmental Protection Act (pilot)
1986
Environmental Protection Management Measure for Construction Projects Environmental Protection Act
Firstly requires EIA as a compulsory component of official approval for predicting and estimating the environmental impacts before the implementation of construction programs and projects, and identify the decision-maker Regulates the screening and scoping processes of EIA and the content of EIS, and identify the decision-maker Replaces the pilot Act, and formally requires EIA as a compulsory component of the official approval to predict and estimate the environmental impacts before the implementation of construction programs and projects, and identify the decision-maker Provides detailed explanations of the steps and requirements of EIA: screening, scoping, assessment, mitigation, and decision-making; and regulates the content of EIA Emphasizes the screening, scoping, and following-up processes of EIA, and identifies the decision-maker Focuses on how to implement EIA besides construction projects and programs, firstly requires EIA to predict and evaluate the environmental impacts of policies, especially planning and developing policies; it identifies the decision-maker and advocates community participation Highlights the environmental health impact of projects, programs, and policies; and introduces HRA as the assessment method
1989
1994 1998 2002
2008
Technical Guideline for Environmental Impact Assessment Environmental Protection Management Regulation for Construction Projects Environmental Impact Assessment Act
Technical Guideline for Environmental Impact Assessment on Human Health (draft)
422
L. Wu et al. / Environmental Impact Assessment Review 31 (2011) 420–424
The arguments for strengthening China's IA system through inclusion of HIA to better assist in population health decision-making can be summarized as follows:
4. The utility of HIA in China The key characteristics of the two current assessment approaches and those of HIA are summarized in Table 2 to allow for comparison. Based on Table 2, the following observations can be made about the current IA system and the utility of HIA for China.
1. The current systems used in China are primarily focused on physical environmental determinants of health and hence are limited in their assessment of the breadth of population health determinants. How social and other non-environmental determinants of general population's health influence health is a major assessment gap in the current IA system in China. For assisting in decision-making relating to population health, HIA has been demonstrated to be a useful and comprehensive tool. 2. The PaOHCP and EIA systems in China have specific and limited assessment objectives. Theoretically HIA as a concept has potential to be applied more broadly to projects, programs or policies. It has been used to assist decision-making across these three activities in many places in the world (Birley, 2004; Dora and Racioppi, 2003; Harris et al., 2007; Lock et al., 2003; Thackway et al., 2005). 3. Compared with PaOHCP and Chinese EIA, HIA not only concentrates on negative impacts, but also positive impacts making recommendations that ensure that positive aspects are enhanced and negative aspects are minimized. For example, recommendations may be made to reduce negative impacts such as reducing air pollution from a new industrial activity and enhance positive impacts such as increasing access to green space in a residential development. Hence HIA can play a significant role in both health promotion and protection. This is particularly important in helping to address issues related to non-communicable (lifestyle) related diseases such as diabetes and cardiovascular disease which are increasing in prevalence in China. 4. One of the important applications of HIA is for addressing health inequality. Health inequality is a challenging issue in public health, which can be effectively addressed by “intersectoral” policies (Mackenbach et al., 2004; Wright et al., 2005). As WHO described, HIA is a tool to identify the distribution of impacts within a population (WHO Regional Office for Europe and European Center for Health Policy, 1999), such as the inequitable distribution of occupational disease in workers in China, where migrant workers suffer from higher rates of occupational injury and disease (Han et al., 2006; Li and Wu, 2008; Xiao, 2007; Yu, 2008). Underpinning the effective use of HIA is multi-sectoral collaboration through identification and analysis of determinants of health. None of the current IA approaches used in China explicitly consider this critical issue of health inequality.
4.1 Assessment objectives HIA as a tool can be applied to broad assessment objectives, including projects, programs, and policies. The focus of PaOHCP is for construction projects and programs and though the Chinese EIA includes application to policy (as well as projects and program), its current application is generally limited to land planning and few development-related policies. Therefore, general policy and nonconstruction projects and programs are blind spots for the current IA system in China. 4.2 Target and breadth of assessment HIA is generally targeted at population health promotion and protection with comprehensive consideration of multiple determinants of health. Though PaOHCP only focuses on occupational health impacts on workers, the draft of the Chinese EIA technical guidelines includes consideration of health for the general population as well as the environment. However both systems are generally most focused on the physical environmental determinants that influence health. 4.3 Focus of effect of impact In contrast to Chinese EIA and PaOHCP systems which are primarily focused on identifying negative impacts, explicit to HIA methodology is the consideration of both negative and positive health impacts. 4.4 Assessment methods HIA utilizes both quantitative and qualitative methods, partly reflecting the strong role of community and other stakeholder engagement underpinning HIA and the consideration of a breadth of health determinants. PaOHCP and EIA in China most commonly use quantitative methods to collect data and evaluate health impacts.
Table 2 A comparison of Chinese EIA and PaOHCP and HIA. Items
Chinese EIA
Chinese PaOHCP
HIA
Assessment objectives
Policy (land planning and developing), program, and Project Screening Scoping Assessment Decision-making Mitigation Follow-up Quantitative Negative General population and environment
Construction projects and programs
Any project, program, and policy
Screening Scoping Assessment Decision-making Recommendation Monitoring Quantitative Negative Occupational groups
Screening Scoping Assessment Decision-making Recommendation Monitoring Mixed methods: quantitative and qualitative Positive and negative General population
– √
– √
√ √
– – –
– – –
√ √ √
Steps
Assessment methods Focus of effect of impact Target and breadth of assessment Determinants considered Individual Physical environmental (including chemical, physical, radioactive, and biological) Social Cultural Accessibility of health services
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5. Recommendations for the future development of HIA in China Section 4 established that HIA would significantly enhance China's impact assessment system, filling many of the gaps identified in the existing system. International experience suggests that there are six key factors necessary for successful application of HIA. They include intersectoral communication and collaboration, comprehensive stakeholder participation, scientific and conditional scoping, adequate HIA process training, holistic concept of health for HIA practitioners, and emphasis on the positive and negative outcomes (Lock and McKee, 2005). For the successful application of HIA in China, first a HIA framework needs to be developed by the health department. Such a framework should include guidelines for application and consideration of how HIA can best be implemented in the Chinese government decision-making context and existing impact assessment system with consideration given to issues such as the identity and role of the executive agency of HIA projects; the role and participation of other agencies, organizations, and communities; the scope of application; and the type of framework, legislative or otherwise, that could be best developed to ensure the use of HIA in decision-making. If commitment to HIA is progressed then other areas of work relating to workforce capacity, methodology and information and intersectoral collaboration and stakeholder participation need to be developed. 5.1 Building HIA workforce capacity WHO has identified that lack of HIA professionals is a major barrier for the implementation of HIA (Caussy et al., 2003). Hence, it is important to train a group of public health practitioners in the HIA methodology in the initial stage. They can provide leadership to others and undertake the implementation of early HIA projects. As HIA requires collaboration and participation between different departments and organizations in order to effectively assess multiple health determinants, it is important to develop a broad knowledge of health in personnel from other agencies involved in HIA. Such professional development can improve the understanding of HIA and better facilitate intersectoral collaboration and community participation (Dannenberg et al., 2006). 5.2 Developing the HIA methodology In order to best assist decision-making, HIA relies on a comprehensive understanding of the relationship between determinants and health impacts within the project, policy, program being assessed. Unlike traditional methods of assessment such as Health Risk Assessment, HIA also incorporates social determinants and has a strong emphasis on community engagement during the assessment process. Hence both quantitative and qualitative methods are commonly used in the data collection and assessment stages of HIA. However, qualitative data are not commonly utilized in the Chinese impact assessment system and useful, newer quantitative methods such as analysis of spatial data are still underutilized. 5.3 Improving intersectoral collaboration and stakeholder participation HIA focuses on various health determinants, and many departments or organizations (other than Health) have a better access and understanding of data related to these determinants. Therefore, intersectoral collaboration is required to assess the breadth of potential impacts and create the multi-approach solutions to deal with them. Stakeholder participation not only refers to the involvement of departments and organizations, but also includes the participation of other groups like experts and the wider community to increase the reliability of qualitative assessment and facilitate
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finding solutions. To ensure HIA is used most efficiently, specific strategies need to be developed to create a more collaborative environment and to encourage full stakeholder engagement (Chu, 1994; World Health Organization, 1986, 1997). Then, if utilized effectively, the application of HIA itself will strengthen collaboration and improve stakeholder engagement, leading to more sustained partnerships. 6. Conclusion China is experiencing rapid environment and lifestyle changes associated with phenomenal socio-economic development. These developments also bring with them many new population health challenges such as the increase in non-communicable diseases and health inequality, greater exposure to unsafe environments and products, and faster and large-scale transmission of infectious diseases. These pressing challenges stem from the many interacting determinants and require comprehensive assessment tools to enhance decisionmaking in the design and planning phase. The usefulness of HIA has been demonstrated in many countries but not yet in China where current EIA and PaOHCP processes are not designed to adequately assess the broad population health impacts related to the implementation of projects, programs, and policies. In this context, this paper argues that in order to better protect and promote population health, China needs to develop HIA as a tool to systematically estimate and predict the health impacts in the planning process prior to the commencement of programs, projects and policies. The paper concludes by recommending future steps for the establishment and implementation success of HIA in China involving the design of a HIA framework, workforce capacity building, design of methodology, intersectoral collaboration and stakeholder engagement. References Birley M. HIA in developing countries. In: Kemm J, Parry J, Palmer S, editors. Health impact assessment: concept, theory, techniques, and applications. New York: Oxford University Press Inc.; 2004. Caussy D, Kumar P, Sein UT. Health impact assessment needs in south-east Asian countries. Bull World Health Organ 2003;81(6):439–43. Chu C. Integrated health and environment: the key to an ecological public health. In: Chu C, Simpson R, editors. Ecological public health: from vision to practice. Nathan: Griffith University & Center for Health Promotion; 1994. p. 1-10. Dannenberg A, Bhatia R, Cole BL, Dora C, Fielding JE, Kraft K, et al. Growing the field of health impact assessment in the United States: an agenda for research and practice. Am J Public Health 2006;96:262–70. Dora C, Racioppi F. Including health in transport policy agendas: the role of health impact assessment analyses and procedures in the European experience. Bull World Health Organ 2003;81:399–403. Glasson J, Therivel R, Chadwick A. In: Glasson J, editor. Introduction to environmental impact assessment. 3 ed. London: Routledge; 2005. Han YZ, Wang ZB, Gu MH, Wu JZ. The occupational hazards affecting farmer-workers in China. J Occup Environ Med 2006;23(3):285–7. Harris P, Harris-Roxas B, Harris E, Kemp L. Health impact assessment: a practical guide. Sydney: Center for Health Equity Training, Research and Evaluation; 2007. International Association for Impact Assessment. About IAIA. [Internet]. Fargo: International Association for Impact Assessment; 2008 [cited 2008 April 28]. Available from: http://www.iaia.org/modx/index.php?id=318. Li MQ, Wu CR. The prevention and control on occupational diseases of the migrant workers. Mod Prev Med 2008;35(3):446–7. Lock K, McKee M. Health impact assessment: assessing opportunities and barriers to intersectoral health improvement in an expanded European Union. J Epidemiol Community Health 2005;59:356–60. Lock K, Gabrijelcic-Blenkus M, Martuzzi M, Otorepec P, Wallace P, Dora C, et al. Health impact assessment of agriculture and food policies: lessons learnt from the Republic of Slovenia. Bull World Health Organ 2003;81(6):391–8. Mackenbach JP, Veerman LV, Barendregt JJ, Kunst AE. Health inequalities and HIA. In: Kemm J, Parry J, Palmer S, editors. Health impact assessment: concept, theory, techniques, and applications. New York: Oxford University Press Inc.; 2004. Ministry of Environmental Protection of China. Technical Guideline for Environmental Impact Assessment on Human Health (draft). [Internet]. Beijing: Ministry of Environmental Protection of China; 2008 [cited 2008 May 10]. Available from: http: //www.mep.gov.cn/info/bgw/bbgth/200804/W020080407518392493258.pdf. Ministry of Health of China. The statistical bulletin of public health development in China, 2008. [Internet]. Beijing: Ministry of Health of China; 2009 [cited 2009 September 11]. Available from: http://www.moh.gov.cn/publicfiles/business/ htmlfiles/mohwsbwstjxxzx/s8208/200904/40250.htm.
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