What is to be done according to the White Paper no. 16?

The Government has presented several proposals in the White Paper (1) concerning the tools necessary for doing health impact assessments. In the first place, proposals for a more precise legislation to secure health impact assessments has to be passed. In the second place, it is necessary to make sure that health impact assessments are parts of the plans for education of relevant personnel. In the third place, it is required to establish a central unit of competence with the obligation to work out methods, summing up experience, building networks, counselling counties and municipalities, and give technical advise and counselling to The Ministry of Health.

A small working group in The Directory of Social and Health Affairs is at present doing the preparatory work necessary to carry out these statements.

How is «the state of the art» in this field?

The book Health Impact Assessment edited by Kemm, Parry & Palmer (2) presents a very useful survey of updated knowledge, «The state of the art», concerning health impact assessments. The summing up chapter embodies an overview of the research, with important conclusions.

What is health impact assessment?

The research described in the book concerning the question has two common characteristics:

• Health impact assessment attempts to predict the consequences of adopting different options.

• Health impact assessment is intended to assist decision makers.

This means that a health impact assessment is a prospective issue, not a retrospective one. Evaluation is another topic, different from health impact assessment. The intention to assist decision makers, implies that a health impact assessment must be performed in such a way that it really permits exerting influence on the decision making process. Another point is that there is a tendency to interpret «health» too narrowly, focusing only on sickness and disease, not involving e.g. determinants of health related to health promotion.

Participation and stakeholder involvement

Stakeholders should be involved in health impact assessment, but it is unclear in which way such involvement contributes to the health impact assessment. Professor Maurice B. Mittelmark, Bergen describes how to involve citizens in health planning, and this is mentioned as an example of participation which may bring additional benefits to the plan.

The need to consider distribution (equity) of impacts

Internationally it seems to be consensus about the need to consider the distribution of impacts within a population. But in this connection there is an important statement in the book:

It is clear that at present there is a mismatch between the aspirations of HIA and the reality of assessments in terms of considering health inequalities in an adequate manner.

Bases for prediction in health impact assessment

A key question in making a health impact assessment is: What has been done of evaluation of effects of the impact on the health in the actual population? A statement in the book about this question is:

To use an often-repeated phrase from the HIA literature, «the stage is set» for HIA. Unfortunately, it sometimes seems that many of the most important «props» are currently missing. In particular, we have few evaluations of actual impacts to feed in the HIA process, and relatively few systematic reviews of the health effects of social interventions and non-health policies. We also need to make better use of the existing evidence, including that of variable quality. Most importantly, if HIA is to fulfil its potential in improving the public health and reducing health inequalities, we need more evaluation of the actual effects of policies and other interventions.

In other words: We often do not have the sufficient knowledge to make health impact assessments, especially not health impact assessments concerning the «strategic» health impact assessments founded on the Investigation Regulative here in Norway. The lack of knowledge is often connected to the fact that we know too little about the health effects of social interventions and non-health policies, and therefore we need more evaluation of effects of policies and other interventions.

Conclusions in the book

The conclusion in this review of the state of the art of health impact assessments is:

The work presented in this book demonstrates the impressive variety and range of work that has taken place in the field of HIA. Health impact assessments has indeed come a long way in the past 10 years, but it needs to improve further both in terms of methodological technique and practical application if it is to truly fulfil its promise and become a useful adjunct to decision making.

What is of importance concerning research in public health and the issue of health impact assessment?

To identify and stimulate research programmes involving both researchers from the public health field and from the social sciences, is of great importance as a prerequisite for doing a health impact assessment. The following issues are important in this kind of research:

How to avoid a too narrow interpretation of a health impact assessment?

A health impact assessment needs to throw light on not only sickness and illness consequences, but also consequences for health promotion determinants. This is relevant especially for proposals in the strategic field, new legislation, budget proposals etc. There exists a lot of knowledge about determinants for sickness and disease, but we need much more knowledge about the positive determinants for health. In other words, there is a need for research engaged to throw light on this topic.

Even distribution (equity) of impacts

The White Paper points out this important issue, but again, there is too little knowledge at hand concerning the problem how to perform assessments about the distribution of impacts.

Bases for prediction in health impact assessment

The conclusion in the review of the literature is clear: We have too sparse research concerning the health effects of non-health policies.

It is thought-provoking that 25 years have elapsed since Aaron Wildawsky presented his famous sentence about the determinants of health: Only 10 percent of the determinants of health owes to the health services, 90 percent to determinants of other kinds. This is perhaps the best known health impact assessment ever undertaken, but at the same time it is a health impact assessment built on almost no real knowledge! And even more sensational, very little has been done of research during these 25 years with the intension to underpin this very wide spread statement by Wildawsky.

Emphasis on health impact assessment is therefore a starting point for research on the determinants of health not only connected to the health services, but also determinants of other kinds, economy, housing, transport, education, culture etc. etc.

The issue of economic valuation

Economic valuation is a very useful instrument «to put health on the scale pan», as The White Paper says. The reasons for that are in short:

• It is probably the most efficient way to implement the weighting and balancing of different impacts. (Also advocated by WHO in the report «Transport, environment and health» from 2000).

• It may be used in similar manners which have been done in the environmental impact assessments carried out in the Norwegian transport sector, which include the value of «statistical lives», different health states and noise annoyance.

Research in this field is therefore another example of the need for more knowledge, if the good intentions in The White Paper should be fulfilled.